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Primary care of adults 2 > Thyroid DOs (5 questions) > Flashcards

Thyroid DOs (5 questions) Flashcards

1
Q

Most common thyroid conditions?

A

Hypothyroidism
Thyrotoxicosis (Hyperthyroidism)

Thyroid Nodules

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2
Q

Gender ratio of hypothyroidism?

A

10 women:1 man

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3
Q

Most common age of hypothyroidism?

A

>50yo

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4
Q

Overt vs subclinical hypothyroidism?

A

Overt: clinical syndrome + elevated TSH and decreased T4 or T3

Subclinical: no typical Sx but elevated TSH and normal circulating thyroid hormone

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5
Q

Who would you screen for thyroid dos? And how?

A
  • Screen high risk populations
  • older women
  • individuals with autoimmunine disorders
  • individuals with a strong family Hx of thyroid disease
  • hx of radioactive iodine Tx or head/ neck irradiation
  • use of med that impair thyroid fx (e.g. contains iodine – amiodarone)
  • Screening test: Measure serum TSH
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6
Q

Symptoms of hypothyroidism

A
  • slowing of metabolic processes: fatigue & weakness, cold intolerance, DOE, wt gain, cognitive dysfunction, mental retardation (infantile onset), constipation, growth failure
  • Accumulation of matrix substances: dry skin, hoarseness, edema
  • Other: decreased hearing, myalgia and paresthesias, depression, menorrhagia, arthralgia, pubertal delay
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7
Q

Signs of hypothyroidism

A
  • slowing of metabolic processes: slow movement and slow speech, delayed relaxation of DTRs, bradycardia, carotenemia
  • Accumulation of matrix substances: coarse skin, puffy face and loss of eyebrows, periorbital edema, enlargement of tongue
  • Other: diastolic HTN, pleural and pericardial effusions, ascites, galactorrhea
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8
Q

What is hyperthyroidism?

A

thyrotoxicosis (lot o thyroid hormone) caused by excessive production of thyroid hormone

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9
Q

Overt vs subclinical hyperthyroidism

A
  • overt: symptomatic, low TSH, high elevated free thyroxine (T4) or free triiodothyronine (T4) levels
  • Subclinical: suppressed TSH but T4 and T3 are wnl, no Sx hyperthyroid
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10
Q

Who tends to get hyperthyroid (gender / age)?

A

women over 50yo

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11
Q

Most common causes of hyperthyroidism?

A
  • Diffuse toxic (hyperfunctioning) goiter
  • Graves’ disease
  • Toxic multinodular goiter
  • Toxic uninodular goiter
  • Thyroid inflammatory diseases (e.g., Hashimoto’s thyroiditis)
  • Postpartum thyroiditis, and subacute thyroiditis
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12
Q

Clinical features of hyperthyroidism

A
  • heat intolerance
  • warm moist skin
  • increased sweating
  • nervousness, irritability, eyelid retraction
  • weakness, myopathy
  • SOB, palpitations, arrhythmias, heart failure
  • increased appetitie, frequent BMs, wt loss
  • Scanty periods
  • eye and skin changes of Grave’s (stare, lid lag, exophthalmos)
  • hair thinning, brittle
  • hyperpigmentation of skin, pruritis and hives
  • onycholysis (Plummer’s nails)
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13
Q

Normal TSH

A

0.5 - 4.5/4.7

(some argue lower limit of 2.5)

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14
Q

Normal T3

A

3.5 - 6.5 pmol/L

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15
Q

Normal T4

A

0.7 - 1.4 ng/mL

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16
Q

What test results would you expect in primary hypothyroidism?

A
  • Increased TSH -usually the only one ordered
  • Decreased T4
  • anti-thyroid Abs if Hashimoto’s
  • Reduced radioactive iodine uptake and thyroid scintiscan (not usually ordered)
17
Q

Clinical mgmt of primary hypothyroidism

A
  • Eliminate thyrotoxic meds/exposure
  • Rx L-thyroxine (synthetic T4)
18
Q

What is a clear cut time to start pharm mgmt of hypothyroidism

A

TSH>10mU/L

FT4

19
Q

L-thyroxine: is it necessary to start slow?

A

Not if young and healthy. Yes if >50 w/underlying cardiac conditions, if elderly (>70), or anyone w/severe ischemic heart disease

20
Q

When would you refer for hypothyroidism?

A

Typically primary care, but refer if:

  • 18 years old or younger
  • unresponsive to therapy, or pregnant (pregnant, usually need to increase T4)
  • cardiac disease, goiter, nodule, or other structural abnormality of thyroid gland
  • coexisting endocrine disease (eg., pituitary disease)
21
Q

Most common causes of hyperthyroid in young v elderly

A
  • younger pts: Graves’ diz and thyroiditis (postpartum)
  • elderly: toxic nodular goiter and/or occur in those being Tx’ed w/ amiodarone
22
Q

What is “apathetic hyperthyroidism”?

A

hyperthyroidism without hyperadrenergic symptoms

23
Q

How do elderly often present w/hyperthyroidism?

A

atrial fib, weight loss, in the absence of “classic” symptoms

24
Q

What test results would you expect in hyperthyroidism?

A
  • usually decreased TSH
  • T4 and T41 usually increased
  • T3 usually increased
  • antithyroid Abs increased in Grave’s
  • Increased radioactive iodine uptake and thyroid scintiscan
25
Q

Clinical mgmt of hyperthyroidism

A
  • Reduce iodine intake (iodine can actually increase or decrease)
  • BB
  • Consult with M.D. re: use of anti-thyroid medications or iodine
  • Refer to M.D. for ablative therapy/surgery
  • Overt hyperthyroidism: refer to specialists
  • Pending referral, β-blocker to control Sxs if not contraindicated (eg., atenolol 25-50mg qd or propranolol 20-40mg 3-4times a day, HR
  • If a long wait is likely before pt is seen by a specialist-initiate treatment with anti-thyroid drugs in consultation with the endocrinologist concerned.
26
Q

How is hyperthyroidism treated?

A
  • Radioiodine Ablation: RAI (131 I) – depends on thyroid size. Normally total ablation, which leads to hypothyroidism and lifelong L-thyroxine
  • Antithyroid Drug – prior to ablation
  • Surgery – typically for toxic adenoma, malignancy
27
Q

What antithyroid drugs are available?

A

Tapazole (methimazole) and propylthiouracil (PTU)

28
Q

How do Tapazole (methimazole) and propylthiouracil (PTU) work?

A

interfere with thyroid hormone synthesis
PTU is also able to inhibit T4 to T3 conversion in peripheral tissues

29
Q

Who is most likely to be Rxed Tapazole or PTU?

A
  • young adults, persons with mild thyrotoxicosis, small goiter
  • Do not permanently damage the thyroid
  • High recurrence rate with drug approach – 3 to 6mths later until PT decides to do more invasive procedure (maybe 50% do have permanent remission.). Tx usually about 1.5 years
30
Q

When would you decide to treat a subclinical thyroid dz?

A
  • women w/ subclinical hypo-T who are pregnant or trying to conceive or pt w/ typical sxs of hypo-T
  • pt w/ increased risk of AF or osteoporosis (Tx parameters)
31
Q

Characteristics of a thyroid nodule you would only monitor?

A
  • not changed for years
  • asymptomatic
  • non-palpable, found incidentally,
32
Q

Characteristics of a thyroid nodule you would send out for a non-urgent referral?

A
  • abnormal thyroid test
  • Hx of sudden onset of pain in a thyroid lump (likely to have bled into a benign thyroid cyst)
  • a thyroid lump which is newly presenting or increasing in size over month
33
Q

Characteristics of a thyroid nodule you would send out for an urgent referral (2 weeks)?

A
  • Notably large size (> 4cm)
  • rapid growth
  • pain
  • hard consistency
  • fixation to adjacent structures
  • local LAN
  • stridor (refer same day) and hoarseness
34
Q

Clinical mgmt of benign thyroid nodules

A

Watchful waiting vs. L-thyroxine suppressive therapy

35
Q

Clinical mgmt of malignant thyroid nodules

A
  • Surgery
  • Radiation
  • L-thyroxine suppressive/replacement therapy
36
Q

Pt presents with amiodarone induced hyperthyroidism. What do you do?

A
  • potential for life threatening cardiac effects (work w/cardiologist & endocrinologist. Can’t just stop it).
  • Key role: check thyroid function test before starting amiodarone, after 3-4 months of therapy and 1 year after discontinuing therapy (every 6 month)
37
Q

Why does amiodarone induce hyperthyroidism?

A

Amiodarone contains substantial amt of iodine. Also, has long half life! Must continue to monitor!

Primary care of adults 2 (15 decks)

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