Podcast
Questions and Answers
The thyroid gland is located in what part of the neck?
The thyroid gland is located in what part of the neck?
- Lower posterior
- Upper posterior
- Upper lateral
- Lower anterior (correct)
What connects the two main lobes of the thyroid gland?
What connects the two main lobes of the thyroid gland?
- Esophagus
- Trachea
- Larynx
- Isthmu (correct)
What is the approximate weight of a healthy thyroid gland?
What is the approximate weight of a healthy thyroid gland?
- 100 grams
- 25 grams (correct)
- 500 grams
- 200 grams
What is the name for an enlarged thyroid gland?
What is the name for an enlarged thyroid gland?
The thyroid gland originates from which structure during embryonic development?
The thyroid gland originates from which structure during embryonic development?
What arteries supply blood to the thyroid gland?
What arteries supply blood to the thyroid gland?
Damage to which nerve during thyroid surgery can cause impairment in phonation?
Damage to which nerve during thyroid surgery can cause impairment in phonation?
What is the functional unit of the thyroid gland?
What is the functional unit of the thyroid gland?
What do parafollicular cells secrete?
What do parafollicular cells secrete?
The thyroid gland secretes which two main hormones?
The thyroid gland secretes which two main hormones?
Which of the following is essential for thyroid hormone synthesis?
Which of the following is essential for thyroid hormone synthesis?
What is the name of the symporter responsible for the uptake of iodine into thyrocytes?
What is the name of the symporter responsible for the uptake of iodine into thyrocytes?
What enzyme promotes the oxidation of iodine for thyroid hormone synthesis?
What enzyme promotes the oxidation of iodine for thyroid hormone synthesis?
The activity of the thyroid gland is regulated by what hormone secreted by the hypothalamus?
The activity of the thyroid gland is regulated by what hormone secreted by the hypothalamus?
In hypothyroidism, is resting energy expenditure increased or reduced?
In hypothyroidism, is resting energy expenditure increased or reduced?
The regulation of thyroid function involves a balance between which two processes?
The regulation of thyroid function involves a balance between which two processes?
What hormone does the hypothalamus secrete to stimulate the pituitary gland in the thyroid axis?
What hormone does the hypothalamus secrete to stimulate the pituitary gland in the thyroid axis?
TSH stimulates which processes in thyroid hormone synthesis?
TSH stimulates which processes in thyroid hormone synthesis?
In cases of reduced levels of circulating T4 and T3, what happens to TSH levels?
In cases of reduced levels of circulating T4 and T3, what happens to TSH levels?
What is the primary characteristic of hypothyroidism?
What is the primary characteristic of hypothyroidism?
In 95% of cases, what is the location of the damage that causes primary hypothyroidism?
In 95% of cases, what is the location of the damage that causes primary hypothyroidism?
What characterizes secondary hypothyroidism?
What characterizes secondary hypothyroidism?
During which phase of the menstrual cycle is biochemical hormonal evaluation usually conducted for premenopausal women?
During which phase of the menstrual cycle is biochemical hormonal evaluation usually conducted for premenopausal women?
In subclinical thyroid dysfunction, what is typically altered?
In subclinical thyroid dysfunction, what is typically altered?
What lab result would indicate overt hypothyroidism?
What lab result would indicate overt hypothyroidism?
In Western countries, what is the most common cause of acquired primary hypothyroidism?
In Western countries, what is the most common cause of acquired primary hypothyroidism?
What is the most common cause of hypothyroidism worldwide?
What is the most common cause of hypothyroidism worldwide?
Congenital hypothyroidism is also known as what?
Congenital hypothyroidism is also known as what?
Clinical or overt hypothyroidism is characterized by what?
Clinical or overt hypothyroidism is characterized by what?
What is a common symptom associated with hypothyroidism due to slowed metabolic activity?
What is a common symptom associated with hypothyroidism due to slowed metabolic activity?
Which skin symptom is commonly associated with hypothyroidism due to vasoconstriction?
Which skin symptom is commonly associated with hypothyroidism due to vasoconstriction?
What is a typical biochemical alteration in patients affected by hypothyroidism?
What is a typical biochemical alteration in patients affected by hypothyroidism?
Overt primary hypothyroidism is characterized by which lab values?
Overt primary hypothyroidism is characterized by which lab values?
What autoantibodies are commonly tested for diagnosing autoimmune thyroiditis?
What autoantibodies are commonly tested for diagnosing autoimmune thyroiditis?
Which of the following is a characteristic finding in patients with Hashimoto's thyroiditis?
Which of the following is a characteristic finding in patients with Hashimoto's thyroiditis?
What does the presence of autoantibodies like anti-thyroglobulin and anti-thyroid peroxidase indicate?
What does the presence of autoantibodies like anti-thyroglobulin and anti-thyroid peroxidase indicate?
What is the treatment for hypothyroidism that involves a thyroid hormone?
What is the treatment for hypothyroidism that involves a thyroid hormone?
Levothyroxine is the synthetic form of which thyroid hormone?
Levothyroxine is the synthetic form of which thyroid hormone?
What condition is a potential contraindication for starting levothyroxine?
What condition is a potential contraindication for starting levothyroxine?
If Eutirox is given to a patient, how will the levothyroxine affect the TSH levels?
If Eutirox is given to a patient, how will the levothyroxine affect the TSH levels?
In the case presented, what prompted Mafalda to seek medical advice?
In the case presented, what prompted Mafalda to seek medical advice?
Mafalda's medical history includes which of the following?
Mafalda's medical history includes which of the following?
What symptom does Mafalda experience related to swallowing?
What symptom does Mafalda experience related to swallowing?
During the clinical evaluation of Mafalda, which of the following was noted?
During the clinical evaluation of Mafalda, which of the following was noted?
What was the result of Mafalda's blood examination regarding thyroid function?
What was the result of Mafalda's blood examination regarding thyroid function?
What is the reported prevalence of clinically palpable thyroid nodules in adults?
What is the reported prevalence of clinically palpable thyroid nodules in adults?
What percentage of thyroid nodules are estimated to be malignant?
What percentage of thyroid nodules are estimated to be malignant?
What initial diagnostic tests are typically performed to assess thyroid nodules?
What initial diagnostic tests are typically performed to assess thyroid nodules?
What is the purpose of measuring calcitonin levels in patients with thyroid nodules?
What is the purpose of measuring calcitonin levels in patients with thyroid nodules?
What does a 'cold nodule' with low iodine intake typically represent?
What does a 'cold nodule' with low iodine intake typically represent?
What is the purpose of Fine Needle Aspiration Cytology (FNAC) in evaluating thyroid nodules?
What is the purpose of Fine Needle Aspiration Cytology (FNAC) in evaluating thyroid nodules?
Which of the following is associated with a higher risk of malignancy in thyroid nodules on US?
Which of the following is associated with a higher risk of malignancy in thyroid nodules on US?
According to the information, what is the significance of the absence of a halo sign in a thyroid nodule?
According to the information, what is the significance of the absence of a halo sign in a thyroid nodule?
What echogenicity characteristic on ultrasound is associated with a higher risk of malignancy in thyroid nodules?
What echogenicity characteristic on ultrasound is associated with a higher risk of malignancy in thyroid nodules?
What finding regarding calcifications is more indicative of malignancy in thyroid nodules?
What finding regarding calcifications is more indicative of malignancy in thyroid nodules?
According to the Bethesda system, what does a TIR4 category indicate?
According to the Bethesda system, what does a TIR4 category indicate?
Which of the following is considered a 'red flag' for malignancy in thyroid nodules?
Which of the following is considered a 'red flag' for malignancy in thyroid nodules?
What factor has been associated with an increased risk of thyroid neoplasms?
What factor has been associated with an increased risk of thyroid neoplasms?
Which is the most common differentiated form of thyroid carcinoma?
Which is the most common differentiated form of thyroid carcinoma?
Which thyroid carcinoma type is known for its aggressive nature and poor prognosis?
Which thyroid carcinoma type is known for its aggressive nature and poor prognosis?
Neuroendocrine tumors originate from which embryonic structure?
Neuroendocrine tumors originate from which embryonic structure?
Which of the following organs does NOT typically contain neuroendocrine cells?
Which of the following organs does NOT typically contain neuroendocrine cells?
What is a key characteristic of neuroendocrine cells that distinguishes them from other cell types?
What is a key characteristic of neuroendocrine cells that distinguishes them from other cell types?
What is the primary reason for the increased diagnosis of neuroendocrine tumors (NETs) in recent decades?
What is the primary reason for the increased diagnosis of neuroendocrine tumors (NETs) in recent decades?
In what age range are neuroendocrine tumors most commonly diagnosed?
In what age range are neuroendocrine tumors most commonly diagnosed?
The gastrointestinal (GI) tract is a common location for neuroendocrine tumors. Which specific area within the GI tract is most frequently affected?
The gastrointestinal (GI) tract is a common location for neuroendocrine tumors. Which specific area within the GI tract is most frequently affected?
What is the most common presentation of non-functioning neuroendocrine tumors?
What is the most common presentation of non-functioning neuroendocrine tumors?
What is the underlying cause of Multiple Endocrine Neoplasia (MEN) syndromes?
What is the underlying cause of Multiple Endocrine Neoplasia (MEN) syndromes?
Which gene is commonly associated with MEN1 syndrome?
Which gene is commonly associated with MEN1 syndrome?
Which of the following is NOT a typical manifestation of MEN1 syndrome?
Which of the following is NOT a typical manifestation of MEN1 syndrome?
The presence of parathyroid adenoma or hyperplasia in MEN1 patients typically leads to what condition?
The presence of parathyroid adenoma or hyperplasia in MEN1 patients typically leads to what condition?
MEN2 syndromes are mainly associated with which two conditions?
MEN2 syndromes are mainly associated with which two conditions?
What is the most important biochemical diagnostic test for detecting hypoglycemia caused by insulinoma?
What is the most important biochemical diagnostic test for detecting hypoglycemia caused by insulinoma?
What peptide, secreted by neuroendocrine tumors, is a marker used in nearly every patient with this condition?
What peptide, secreted by neuroendocrine tumors, is a marker used in nearly every patient with this condition?
Which imaging technique uses a radioactive tracer that specifically binds to somatostatin receptors on neuroendocrine cells?
Which imaging technique uses a radioactive tracer that specifically binds to somatostatin receptors on neuroendocrine cells?
What is a 'buffalo hump' characterized by?
What is a 'buffalo hump' characterized by?
What is a moon face?
What is a moon face?
What is the primary cause of both 'moon face' and 'buffalo hump'?
What is the primary cause of both 'moon face' and 'buffalo hump'?
Which condition is associated with both buffalo hump and moon face?
Which condition is associated with both buffalo hump and moon face?
What laboratory finding is most consistent with Cushing syndrome/disease?
What laboratory finding is most consistent with Cushing syndrome/disease?
What electrolyte abnormalities is consistent with Cushing syndrome/disease?
What electrolyte abnormalities is consistent with Cushing syndrome/disease?
Which of the following clinical findings are associated with Cushing syndrome/disease?
Which of the following clinical findings are associated with Cushing syndrome/disease?
What are the main etiological causes of Cushing syndrome/disease?
What are the main etiological causes of Cushing syndrome/disease?
What is the key test used to diagnose hypercortisolism?
What is the key test used to diagnose hypercortisolism?
A pituitary MRI is useful except in which scenario?
A pituitary MRI is useful except in which scenario?
What is the desirable first-line treatment for Cushing syndrome/disease?
What is the desirable first-line treatment for Cushing syndrome/disease?
What is a condition that can be observed with hypertension?
What is a condition that can be observed with hypertension?
A patient presents with hypertension and hypokalemia. What test is most likely to demonstrate the abnormalities?
A patient presents with hypertension and hypokalemia. What test is most likely to demonstrate the abnormalities?
Which of the following is a finding expected with pheochromocytoma?
Which of the following is a finding expected with pheochromocytoma?
What is the most specific radiologic test to confirm pheochromocytoma?
What is the most specific radiologic test to confirm pheochromocytoma?
Which medication should a patient receive before undergoing surgical intervention to manage pheochromocytoma?
Which medication should a patient receive before undergoing surgical intervention to manage pheochromocytoma?
For an asymptomatic non-secreting adrenal adenoma measuring 1.4 x 1.5 cm, what is the recommended action?
For an asymptomatic non-secreting adrenal adenoma measuring 1.4 x 1.5 cm, what is the recommended action?
Which disease is indicated by an increase of 17(OH)progesterone?
Which disease is indicated by an increase of 17(OH)progesterone?
What is a prominent feature of early onset 21-hydroxylase deficiency in female infants?
What is a prominent feature of early onset 21-hydroxylase deficiency in female infants?
Which of the following main pathological feature observed with late onset 21-hydroxylase deficiency?
Which of the following main pathological feature observed with late onset 21-hydroxylase deficiency?
What is the best testing method for 21-hydroxylase deficiency diagnosis?
What is the best testing method for 21-hydroxylase deficiency diagnosis?
Which test is most used for osteoporosis diagnosis?
Which test is most used for osteoporosis diagnosis?
What T-score range obtained from a DXA scan indicates osteoporosis?
What T-score range obtained from a DXA scan indicates osteoporosis?
Which combination represents key risk factors for osteoporosis?
Which combination represents key risk factors for osteoporosis?
What can vertebral morphometry detect?
What can vertebral morphometry detect?
What is a key finding for patients with primary hyperparathyroidism?
What is a key finding for patients with primary hyperparathyroidism?
Which of these is seen in primary hyperparathyroidism?
Which of these is seen in primary hyperparathyroidism?
A patient has low calcium. Which complication is not common?
A patient has low calcium. Which complication is not common?
Which is seen with primary hyperparathyroidism?
Which is seen with primary hyperparathyroidism?
Which cause underlies secondary hyperparathyroidism?
Which cause underlies secondary hyperparathyroidism?
What is the first-line treatment for parathyroid adenoma with primary hyperparathyroidism?
What is the first-line treatment for parathyroid adenoma with primary hyperparathyroidism?
What examination should you use if the patient has a parathyroid disorder?
What examination should you use if the patient has a parathyroid disorder?
What is the first-line treatment in a patient with secondary hyperparathyroidism?
What is the first-line treatment in a patient with secondary hyperparathyroidism?
What conditions are associated with primary hypoparathyroidism?
What conditions are associated with primary hypoparathyroidism?
What biochemical findings are expected in hypoparathyroidism?
What biochemical findings are expected in hypoparathyroidism?
The accumulation of adipose tissue particularly in the nuchal zone is characteristic of which condition?
The accumulation of adipose tissue particularly in the nuchal zone is characteristic of which condition?
A rounded appearance of the face due to fat deposits on the sides of the face is referred to as what?
A rounded appearance of the face due to fat deposits on the sides of the face is referred to as what?
Redistribution of fat in other areas is the cause for which signs?
Redistribution of fat in other areas is the cause for which signs?
Buffalo hump and moon face are signs observed in which condition?
Buffalo hump and moon face are signs observed in which condition?
Which pathological finding is observed in all patients with Cushing syndrome/disease?
Which pathological finding is observed in all patients with Cushing syndrome/disease?
Hyperglycemia, hypernatremia, and hypokalemia are main pathological biochemical findings observed in which disease?
Hyperglycemia, hypernatremia, and hypokalemia are main pathological biochemical findings observed in which disease?
If a patient has skeletal impairment, diabetes mellitus, and hypertension, which condition is likely?
If a patient has skeletal impairment, diabetes mellitus, and hypertension, which condition is likely?
Which of the following is the most common etiological cause of Cushing Syndrome?
Which of the following is the most common etiological cause of Cushing Syndrome?
For Cushing syndrome/disease diagnosis, which biochemical test is optimal?
For Cushing syndrome/disease diagnosis, which biochemical test is optimal?
What is the optimal radiological testing for a Cushing syndrome/disease diagnosis?
What is the optimal radiological testing for a Cushing syndrome/disease diagnosis?
Hypertension can be observed in which pathological condition?
Hypertension can be observed in which pathological condition?
Which biochemical finding is observed in patients with Conn’s Syndrome?
Which biochemical finding is observed in patients with Conn’s Syndrome?
Which clinical finding is observed in patients with Pheochromocytoma?
Which clinical finding is observed in patients with Pheochromocytoma?
The initial medical approach in patients with pheochromocytoma involves the use of?
The initial medical approach in patients with pheochromocytoma involves the use of?
What is the desirable first-line treatment for a non-secreting adrenal adenoma measuring 1.4x1.5 cm?
What is the desirable first-line treatment for a non-secreting adrenal adenoma measuring 1.4x1.5 cm?
Higher 17(OH)progesterone levels is caused by which condition?
Higher 17(OH)progesterone levels is caused by which condition?
Salt-wasting crises and virilization of female infants is characteristic of which condition?
Salt-wasting crises and virilization of female infants is characteristic of which condition?
In late-onset 21-hydroxylase deficiency, which of the main pathological findings is observed in patients?
In late-onset 21-hydroxylase deficiency, which of the main pathological findings is observed in patients?
Which test is considered the gold-standard biochemical test for late-onset 21-hydroxylase deficiency diagnosis?
Which test is considered the gold-standard biochemical test for late-onset 21-hydroxylase deficiency diagnosis?
What is the main important and most used test for osteoporosis diagnosis?
What is the main important and most used test for osteoporosis diagnosis?
What DXA T-score values indicate an osteoporosis diagnosis?
What DXA T-score values indicate an osteoporosis diagnosis?
Which combination is the risk factor in osteoporosis?
Which combination is the risk factor in osteoporosis?
Which test is useful to investigate osteoporosis severity?
Which test is useful to investigate osteoporosis severity?
Which pathological biochemical finding is observed in patients with primary hyperparathyroidism?
Which pathological biochemical finding is observed in patients with primary hyperparathyroidism?
What are the main pathological findings observed in patients with primary hyperparathyroidism?
What are the main pathological findings observed in patients with primary hyperparathyroidism?
Which of the following is not a common complication of primary hyperparathyroidism?
Which of the following is not a common complication of primary hyperparathyroidism?
What are the main pathological causes underlying primary hyperparathyroidism?
What are the main pathological causes underlying primary hyperparathyroidism?
What are the main pathological causes underlying secondary hyperparathyroidism?
What are the main pathological causes underlying secondary hyperparathyroidism?
What is the desirable first-line treatment for a parathyroid adenoma with primary hyperparathyroidism?
What is the desirable first-line treatment for a parathyroid adenoma with primary hyperparathyroidism?
What is the most useful exam for parathyroid adenoma diagnosis?
What is the most useful exam for parathyroid adenoma diagnosis?
Which is the desirable first-line treatment in a patient with secondary hyperparathyroidism?
Which is the desirable first-line treatment in a patient with secondary hyperparathyroidism?
What are the main pathological biochemical findings observed in patients with hypoparathyroidism?
What are the main pathological biochemical findings observed in patients with hypoparathyroidism?
What is the main pathological clinical finding in patients with hypoparathyroidism?
What is the main pathological clinical finding in patients with hypoparathyroidism?
What past medical conditions has Giacomo been diagnosed with?
What past medical conditions has Giacomo been diagnosed with?
What prompted Giacomo to seek a specialized assessment?
What prompted Giacomo to seek a specialized assessment?
According to the thyroid ultrasound, what characteristics does the nodule in Giacomo's thyroid have?
According to the thyroid ultrasound, what characteristics does the nodule in Giacomo's thyroid have?
What were Giacomo's TSH and fT4 levels relative to the normal range?
What were Giacomo's TSH and fT4 levels relative to the normal range?
What was found in Giacomo's blood examinations regarding thyroid autoantibodies?
What was found in Giacomo's blood examinations regarding thyroid autoantibodies?
What recent weight change has Giacomo experienced?
What recent weight change has Giacomo experienced?
What is Giacomo's current arterial pressure?
What is Giacomo's current arterial pressure?
What observation was made during Giacomo's thoracic examination?
What observation was made during Giacomo's thoracic examination?
During the abdominal examination, what observation was made about Giacomo?
During the abdominal examination, what observation was made about Giacomo?
What initial clinical observation raised suspicion for acromegaly in Giacomo?
What initial clinical observation raised suspicion for acromegaly in Giacomo?
What clinical feature involving the teeth is shown in the image provided?
What clinical feature involving the teeth is shown in the image provided?
What facial characteristic is shown in the image?
What facial characteristic is shown in the image?
Which condition is depicted in the tongue image provided?
Which condition is depicted in the tongue image provided?
What is recommended as the next step after the initial physical examination for Giacomo?
What is recommended as the next step after the initial physical examination for Giacomo?
Why is FNA crucial for Giacomo?
Why is FNA crucial for Giacomo?
What examinations are required to exclude secondary causes of diabetes and hypertension in Giacomo?
What examinations are required to exclude secondary causes of diabetes and hypertension in Giacomo?
In Giacomo's biochemical evaluation, which hormones had normal levels?
In Giacomo's biochemical evaluation, which hormones had normal levels?
In your suspicion of acromegaly, which blood examination is most useful?
In your suspicion of acromegaly, which blood examination is most useful?
Based on the oral glucose tolerance test (OGTT) in Giacomo, what physiologic response of GH levels is expected?
Based on the oral glucose tolerance test (OGTT) in Giacomo, what physiologic response of GH levels is expected?
In suspected acromegaly, which diagnostic examination is most useful?
In suspected acromegaly, which diagnostic examination is most useful?
What is Giacomo's approximate Body Mass Index (BMI)?
What is Giacomo's approximate Body Mass Index (BMI)?
What is Giacomo's reported smoking history?
What is Giacomo's reported smoking history?
What previous conditions has Giacomo been diagnosed with?
What previous conditions has Giacomo been diagnosed with?
What type of thyroid issue was recently detected in Giacomo?
What type of thyroid issue was recently detected in Giacomo?
According to the thyroid ultrasound, what is present in Giacomo's thyroid?
According to the thyroid ultrasound, what is present in Giacomo's thyroid?
According to the thyroid ultrasound, where is the larger nodule located?
According to the thyroid ultrasound, where is the larger nodule located?
What characteristics describe the margins of the larger thyroid nodule?
What characteristics describe the margins of the larger thyroid nodule?
For Giacomo, what do the blood examinations reveal regarding thyroid autoantibodies?
For Giacomo, what do the blood examinations reveal regarding thyroid autoantibodies?
What weight change has Giacomo experienced in the last year?
What weight change has Giacomo experienced in the last year?
What was noted during Giacomo's thoracic examination?
What was noted during Giacomo's thoracic examination?
What observation was made during Giacomo's abdominal examination?
What observation was made during Giacomo's abdominal examination?
What is indicated by increased space between the teeth?
What is indicated by increased space between the teeth?
What condition is characterized by a jutting out of the lower jaw?
What condition is characterized by a jutting out of the lower jaw?
What is the medical term for enlargement of the tongue?
What is the medical term for enlargement of the tongue?
What is the recommended next step in Giacomo's evaluation, after FNAC?
What is the recommended next step in Giacomo's evaluation, after FNAC?
During initial blood examinations for Giacomo, which hormone levels were considered normal?
During initial blood examinations for Giacomo, which hormone levels were considered normal?
Which blood examination could be useful in the clinical suspicion for Giacomo?
Which blood examination could be useful in the clinical suspicion for Giacomo?
What is the physiological response of GH levels to OGTT?
What is the physiological response of GH levels to OGTT?
Which radiological exam is most useful for initial acromegaly testing?
Which radiological exam is most useful for initial acromegaly testing?
What is the definition of oligomenorrhea?
What is the definition of oligomenorrhea?
For a patient with the symptoms and lab results as Sofia, which diagnostic test is the most appropriate next step?
For a patient with the symptoms and lab results as Sofia, which diagnostic test is the most appropriate next step?
Which examinations should we request for Sofia?
Which examinations should we request for Sofia?
Based on Sofia's lab results, which result is NOT within normal range?
Based on Sofia's lab results, which result is NOT within normal range?
Based on Sofia's lab results, what condition is most likely?
Based on Sofia's lab results, what condition is most likely?
According to the content for elevated prolactin coupled with a thyroid issue, what role does TRH play?
According to the content for elevated prolactin coupled with a thyroid issue, what role does TRH play?
For Sofia, what diagnostic examination could be useful to further investigate the cause of her condition?
For Sofia, what diagnostic examination could be useful to further investigate the cause of her condition?
Based on the provided information, which autoantibodies are most relevant for the evaluation of Sofia's condition?
Based on the provided information, which autoantibodies are most relevant for the evaluation of Sofia's condition?
Which features would be most likely to observe at thyroid US for Sofia?
Which features would be most likely to observe at thyroid US for Sofia?
In Sofia's case, the patient underwent the examinations and was found with positive anti-thyroid peroxidase and anti-thyroglobulin. What is Sofia's final diagnosis?
In Sofia's case, the patient underwent the examinations and was found with positive anti-thyroid peroxidase and anti-thyroglobulin. What is Sofia's final diagnosis?
In Sofia's case, what is the most appropriate first-line treatment?
In Sofia's case, what is the most appropriate first-line treatment?
What is the goal of adding amiodarone to a patient's medical plan?
What is the goal of adding amiodarone to a patient's medical plan?
In pregnancy, why might the dosage of Levothyroxine need to be adjusted for patients affected by hypothyroidism?
In pregnancy, why might the dosage of Levothyroxine need to be adjusted for patients affected by hypothyroidism?
What is the possible diagnosis for Giovanni, an older patient with cardiac comorbidities, based on the medical history?
What is the possible diagnosis for Giovanni, an older patient with cardiac comorbidities, based on the medical history?
What is the best course of action for Giovanni?
What is the best course of action for Giovanni?
According to the passage, which manifestation differentiates clinical hyperthyroidism from thyrotoxicosis?
According to the passage, which manifestation differentiates clinical hyperthyroidism from thyrotoxicosis?
For a patient such as Eva, with suspected thyrotoxicosis, which diagnostic examination could be useful?
For a patient such as Eva, with suspected thyrotoxicosis, which diagnostic examination could be useful?
For a patient such as Eva, with suspected thyrotoxicosis, what features can we observe at thyroid US?
For a patient such as Eva, with suspected thyrotoxicosis, what features can we observe at thyroid US?
What is Eva's diagnosis?
What is Eva's diagnosis?
According to the provided information, what other diagnostic examination could be valuable for patients affected with exophthalmos?
According to the provided information, what other diagnostic examination could be valuable for patients affected with exophthalmos?
What is the most appropriate first-line treatment for Eva?
What is the most appropriate first-line treatment for Eva?
What is the desirable first-line Thioamide treatment for Eva?
What is the desirable first-line Thioamide treatment for Eva?
According to the passage, Which of the following is a relatively well known side effect of Methimazole?
According to the passage, Which of the following is a relatively well known side effect of Methimazole?
In clinical cases of untreated subacute thyroiditis, what can this lead to?
In clinical cases of untreated subacute thyroiditis, what can this lead to?
Flashcards
Thyroid Gland Location
Thyroid Gland Location
Located in the lower anterior neck, composed of two lobes connected by an isthmus.
Thyroid Vascularization
Thyroid Vascularization
Superior and inferior thyroid arteries.
Nerves Near Thyroid
Nerves Near Thyroid
Right and left recurrent laryngeal nerves.
Parathyroid Gland Damage Complication
Parathyroid Gland Damage Complication
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Thyroid Follicle
Thyroid Follicle
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Colloid Contents
Colloid Contents
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Calcitonin Source
Calcitonin Source
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Main Thyroid Hormones
Main Thyroid Hormones
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Iodine Uptake
Iodine Uptake
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Iodine Oxidation Enzyme
Iodine Oxidation Enzyme
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Main Thyroid Hormone Carrier
Main Thyroid Hormone Carrier
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Hypothalamic Control
Hypothalamic Control
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Negative Feedback
Negative Feedback
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First-Line Thyroid Imaging
First-Line Thyroid Imaging
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Common Cause of Hypothyroidism
Common Cause of Hypothyroidism
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Hypothyroidism
Hypothyroidism
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Hypothalamus-pituitary-thyroid axis
Hypothalamus-pituitary-thyroid axis
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TRH (Thyrotropin-Releasing Hormone)
TRH (Thyrotropin-Releasing Hormone)
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TSH (Thyroid-Stimulating Hormone)
TSH (Thyroid-Stimulating Hormone)
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Negative feedback (thyroid)
Negative feedback (thyroid)
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Thyrotoxicosis
Thyrotoxicosis
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Primary Hypothyroidism
Primary Hypothyroidism
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Secondary (Central) Hypothyroidism
Secondary (Central) Hypothyroidism
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Acquired hypothyroidism
Acquired hypothyroidism
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Congenital hypothyroidism
Congenital hypothyroidism
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Primary Hypothyroidism (slide definition)
Primary Hypothyroidism (slide definition)
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Secondary or Central Hypothyroidism (slide definition)
Secondary or Central Hypothyroidism (slide definition)
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Peripheral Resistance to Thyroid Hormones (Refetoff Syndrome)
Peripheral Resistance to Thyroid Hormones (Refetoff Syndrome)
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Overt thyroid dysfunction
Overt thyroid dysfunction
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Subclinical thyroid dysfunction
Subclinical thyroid dysfunction
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Subacute thyroiditis
Subacute thyroiditis
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Iatrogenic hypothyroidism
Iatrogenic hypothyroidism
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Acquired Primary Hypothyroidism
Acquired Primary Hypothyroidism
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Symptoms of hypothyroidism
Symptoms of hypothyroidism
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Anti-thyroid peroxidase (TPO) antibody and anti-thyroglobulin antibody
Anti-thyroid peroxidase (TPO) antibody and anti-thyroglobulin antibody
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Hashitoxicosis
Hashitoxicosis
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Autoantibodies
Autoantibodies
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Amiodarone
Amiodarone
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Adrenal insufficiency
Adrenal insufficiency
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Wolff-Chaikoff effect
Wolff-Chaikoff effect
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Neck Enlargement
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Dysphagia
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Normal Hemodynamics
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No Tremors/Exophthalmos
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Thyroid Incidentalomas
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TSH, fT4
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Thyroid Ultrasound
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Epithelial Thyroid Carcinomas
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Medullary Carcinoma
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TIR4 category
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Suppression Therapy
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Radioiodine Treatment (RAI)
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Anaplastic carcinoma
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Multiple Endocrine Neoplasia (MEN)
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Neuroendocrine Tumors
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Neuroendocrine Cell Properties
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Increased NET Diagnosis
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Common NET Locations
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Hyperfunctioning Tumors
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MEN1 Syndrome
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Pancreatic NETs in MEN1
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MEN2 Syndromes
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Pheochromocytoma in MEN2
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Carcinoid Syndrome
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Buffalo hump
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Moon Face
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Fat redistribution causes
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Cushing's Syndrome/Disease
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Increased Cortisol Levels
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Electrolyte Imbalance in Hypercortisolism
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Pathological Findings in Cushing's
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Etiological Causes of Cushing Syndrome
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Optimal Testing for Cushing's
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First line treatment Cushing syndrome/disease
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Pheochromocytoma
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Pathological Conditions and Hypertension
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main pathological biochemical findings for Conn's syndrome
main pathological biochemical findings for Conn's syndrome
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Pheochromocytoma Finding
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Pheochromocytoma signs
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Pheochromocytoma Preparation
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Asymptomatic Adrenal Lump
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Which of the following pathological condition can we typically observe higher 17(OH)progesterone levels?
Which of the following pathological condition can we typically observe higher 17(OH)progesterone levels?
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21-hydroxylase deficiency affects
21-hydroxylase deficiency affects
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Gold Standard Test
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Most important test
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Risk Factor for Osteroporosis occurrence
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Osteoporisis Severety
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Primary hyperPT findings
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Primary hyperPT symptoms
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Common complication of hyperPT
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main PA causes
main PA causes
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SPTH Causes
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PT adenoma with primary hyperparathyroism
PT adenoma with primary hyperparathyroism
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US
US
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Secondary PT therapy
Secondary PT therapy
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HypoPT symptoms
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Main Biochemical Finding in HypoPT
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HypoPT clinical findings
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high production of melanins
high production of melanins
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Primary hypoparathyroidism
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Symptoms of hypoparathyroidism
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Primary Hypoparathyroidism Treatment
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Post-Thyroidectomy Symptoms
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Congenital Adrenal Hyperplasia Indicator
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21-Hydroxylase Test
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Secondary Hyperaldosteronism
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Parathyroid Adenoma
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Recurrent laryngeal nerve Symptoms
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What is Synacthen?
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Early follicular phase
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Oligomenorrhea
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Congenital Adrenal Hyperplasia Signs
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Synacthen test
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Which of the fallowing is related to wrist fracture?
Which of the fallowing is related to wrist fracture?
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What is causing secondary hyper...?
What is causing secondary hyper...?
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Drug for treatment of osteo
Drug for treatment of osteo
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Osteoporosis common problem
Osteoporosis common problem
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Non-alcoholic steato...
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What Vitamin d in patient?
What Vitamin d in patient?
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Bones most fragile?
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Evaluate hirsutism?
Evaluate hirsutism?
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Diagnosis In Patient.
Diagnosis In Patient.
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Obesity Grade 1 BMI
Obesity Grade 1 BMI
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Arterial Hypertension
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Diabetes Mellitus Type 2
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Multi Nodular Thyroid Goitre
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Irregular Margins (Thyroid Nodules)
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Microcalcifications (Thyroid)
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Hashimoto's Thyroiditis
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Elevated Blood Pressure
Elevated Blood Pressure
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General Increase in Thyroid Size
General Increase in Thyroid Size
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Distinctive Facial Appearance (Acromegaly)
Distinctive Facial Appearance (Acromegaly)
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Increased Dental Diastasis/Diastema
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Prognathism
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Macroglossia
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Acral Changes
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Blood Examinations
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Pituitary, Adrenal Function Examinations
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Elevated GH, IGF-1, Glycemia
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Oral Glucose Tolerance Test for GH
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Macroadenomas
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Bitemporal Hemianopsia
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Acromegaly
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Sleep Apnea (in Acromegaly)
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Colon cancer (in Acromegaly)
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Tumor Risks in Acromegaly
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Fine Needle Aspiration (FNA)
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Prolactinomas
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Prolactin Curve
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PET-Ga68 Scan
PET-Ga68 Scan
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Wait and see
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Whipple triad
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Hypercalcemia
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Congenital Adrenal Hyperplasia
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Asthenia
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Bradycardia
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Galactorrhea
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Hirsutism
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Clinical Hypothyroidism
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Subclinical Hypothyroidism
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TRH effect on prolactin
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Iatrogenic thyrotoxicosis
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Graves' Disease
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Plummer adenoma
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FNAC
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TIR4 thyroid nodule
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TIR3b
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Thyroid Scintigraphy
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Anti-TSH Receptor autoantibodies (TRAb)
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Subclinical hypothyroidism
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Study Notes
Introduction to Clinical Exercises
- A series of five lessons focuses on endocrine clinical cases
- The lessons focus on pituitary, adrenal, thyroid, parathyroid, and metabolic diseases
- The final two lessons emphasize obesity, diabetes, hypogonadism, and hypercholesteremia
- The current lesson's exam has 30 questions: 15 on Endocrinology, 8-9 on Nephrology, remaining on Urology, Pharmacology, and General Surgery
- Question numbers per section are related to credit values
- During the exam, going back and forth between questions is allowed
Question #1: Buffalo Hump
- Buffalo hump is an accumulation of adipose tissue specifically in the nuchal zone
- Gynecomastia is an increase in male breast glandular tissue
- Adipomastia is an increase in adipose tissue
- Dorsal soft tissue lipoma is a localized, well-rounded lesion
Question #2: Moon Face
- Moon face is a medical sign where the face develops a rounded appearance
- This sign is due to fat deposits on the sides of the face
Question #3: Fat Redistribution
- Both moon face and buffalo hump result from fat redistribution to different tissues
- The redistribution of adipose tissue is related to specific endocrine disorders
Question #4: Cushing's Relationship to Moon Face and Buffalo Hump
- Moon face and buffalo hump are related to hypercortisolism (any condition of hypercortisolism) regardless of the cause (endogenous or exogenous).
- Cushing disease is a subset of Cushing syndrome
- Cushing disease is linked to a pituitary adenoma hypersecreting ACTH in an ACTH-dependent form (pituitary adenoma = Cushing disease).
Question #5: Cushing's and Cortisol Levels
- An increasing cortisol level is present in both Cushing's syndrome and Cushing's disease in either the ACTH-dependent or ACTH-independent form.
Question #6: Cortisol's Effect on Electrolytes
- One of the most common signs of hypercortisolism (Cushing disease/syndrome/iatrogenic hypercortisolism) is hyperglycemia.
- Excess cortisol can act like aldosterone, increasing sodium absorption and promoting potassium excretion in renal tubules leading to hypernatremia and hypokalemia
- Conn’s syndrome has similar effects
- Conn’s syndrome is characterized by an adrenal adenoma that hypersecretes aldosterone.
- Conn’s syndrome patients present with hypertension, hypernatremia, and hypokalemia
Question #7: Excess Cortisol and Skeletal Health
- Excess cortisol reduces osteoblast activity (bone formation) and increases osteoclast activity (bone resorption)
- Excess Cortisol leads to skeletal impairment, osteopenia (bone density loss), and muscle impairment.
- Hypercortisolism can lead to diabetes and hyperglycemia
- Hypertension typically associates with Cushing's syndrome
- Ensure to carefully read options, first two options can be correct answers except the third
Question #8: Etiology of Cushing's
- The most common causes of hypercortisolism involve ACTH-secreting adenoma and Iatrogenic Cushing syndrome, which is related to prolonged glucocorticoid therapy (most common cause of hypercortisolism in the general population).
- Paraneoplastic secretion of adrenocorticotropic hormone is less common than adrenal adenoma secreting cortisol.
Question #9: Diagnosing Hypercortisolism
- For diagnosing hypercortisolism, urinary 24-h test is more important to evaluate versus ACTH stimulation test.
- ACTH test = stimulating test and is used in two conditions including
- Congenital adrenal hyperplasia: stimulates secretion of 17-hydroxyprogesterone
- Adrenal insufficiency (Addison's disease)
Question #10: Radiological Testing for Cushing's
- Chest CT scan is useful for patients suspected of ectopic ACTH production
- i.e. paraneoplastic Cushing's syndrome (commonly related to pulmonary tumors).
- Abdominal X-ray is not useful.
- Brain CT scan is not the recommended radiological examination for a pituitary adenoma
- Pituitary MRI is the recommended radiological examination to observe and examine the pituitary gland.
- CT scans used when MRI is contraindicated
Question #11: Cushing's, Acromegaly and Prolactinoma treatment
- Pituitary or adrenal adenomas hypersecreting cortisol use surgical removal
- Prolactinoma uses medical therapy with a dopamine agonist
- The medical treatment can act on both reducing the adenoma secretion and dimensions
Question #12: Hypertension and Endocrine Conditions
- Hypertension results from Conn's syndrome because of increasing aldosterone levels and resulting sodium and water retention
- Hypertension can also be seen in Pheochromocytoma, due to hypersecretion of catecholamines.
Question #13: Conn's Syndrome Characteristics
- Conn's syndrome is characterized by aldosterone hypersecretion from an adrenal adenoma
- The result is hypokalemia due to aldosterone stimulating renal uptake of sodium and excretion of potassium
Question #14: Pheochromocytoma and Catecholamines
- Pheochromocytoma is associated with increased catecholamine levels
- Catecholamines lead to vasoconstriction, increased heart rate, increased arterial pressure, and hypertension which leads to headache. Peripheral vessels then dilate to release the extra energy.
- Endocrinal diabetes mellitus can rarely develop in Pheochromocytoma (increased levels of catecholamines can stimulate glucose production).
- Calcitonin is a hormone released by parafollicular cell and is increased in patients with medullary thyroid carcinoma
Question #15: Confirmation of Pheochromocytoma
- MIBG scintigraphy is a nuclear medicine imaging technique using a radiolabeled tracer to detect neuroendocrine tumors including Pheochromocytomas
- The radiolabeled tracer is picked up by tumor cells and emits gamma radiation, detected by a gamma camera
Question #16: Presurgical Preparation for Pheochromocytoma
- Catecholamines target alpha receptors
- Patients with Pheochromocytoma usually require alpha-blockers initially, followed surgical treatment
- A fatal complication can result from adequate control of catecholamine levels before initiating surgery
Question #17: Managing Non-Functioning Adrenal Adenomas
- Asymptomatic Non-secreting adrenal adenomas between 1 and 2 cm are managed by observation without intervention.
- Surgical removal is indicated for hypersecreting adrenal adenomas and those measuring around 4-5 cm.
- Radiation therapy is not recommended
Question #18: Congenital Adrenal Hyperplasia Diagnosis
- Increased levels of 17-OH-progesterone is a sign of congenital adrenal hyperplasia
Question #19: Early-Onset 21-Hydroxylase Deficiency Findings
- Early-onset 21-hydroxylase deficiency leads to salt-wasting crises, where impaired aldosterone production causes life-threatening dehydration and electrolyte imbalances
- Cortisol deficiency promotes increased production of androgens, leading to virilization of females and precocious puberty in both sexes
Question #20: Late-Onset 21-Hydroxylase Deficiency Findings
- Late-onset 21-hydroxylase deficiency is less severe, characterized by a mild increase in androgen levels, which is unrelated to imbalances in cortisol and aldosterone.
- Virilization is tied more closely to early-onset deficiency
Question #21: Diagnostic Test for 21-Hydroxylase Deficiency
- Synacthen test consists of administering ACTH to stimulate cortisol production, then measuring cortisol levels
- Elevated 17-OHP levels with the Synacthen test suggest impaired 21-hydroxylase activity
- The most used exam for Osteoporosis diagnosis is a DXA scan of the vertebral and femoral sites
Question #22: Osteoporosis DXA Cutoffs
- Normal bone density has T-score of -1.0 SD or above
- Osteopenia (low bone density) has T-score between -1.0 and -2.5 SD
- Osteoporosis has T-score of -2.5 SD or below
Question #23: Risk Factors for Osteoporosis
- Glucocorticoid treatment is a leading risk factor for osteoporosis
- Amenorrhea is a risk factor due to hormonal imbalances that can cause decreased bone formation and increased bone resorption
- Underweight contributes to low bone mineral density in osteoporosis
Question #24: Investigating Osteoporosis Severity
- Vertebral morphometry used to identify vertebral fractures even when symptoms and bone mineral density are normal to assess Osteoporosis severity
Question #25: Biochemical Findings in Primary Hyperparathyroidism
- Hallmark sign is hypercalcemia because of increased calcium release from bones, intestinal calcium absorption, and reduced renal calcium excretion caused by excessive PTH
- In Primary hyperparathyroidism, Hyper-PTH is where despite the presence of hypercalcemia due to elevated PTH, PTH secretions still increase.
Question #26: Symptoms of Hyperparathyroidism
- GI and neurological symptoms can occur in hyperparathyroidism
Question #27: Complications of Hyperparathyroidism
- Tetanic crises are indicative of hypocalcemia
- Hyperparathyroidism Symptoms:
- Hyperparathyroidism: High levels of calcium in the blood (hypercalcemia) can cause various symptoms, but usually kidney stones and acute hypercalcemia are common
- Kidney Stones
- Osteoporosis: Over time, the loss of calcium may lead to osteoporosis, causing bones to become brittle and more prone to fractures.
Question #28: Causes of Primary Hyperparathyroidism
- The most common cause is hypersecreting parathyroid adenoma
Question #29: Causes of Secondary Hyperparathyroidism
- The difference between primary, secondary, and tertiary hyperparathyroidism relies on the origin/consequences
- Secondary hyperparathyroidism often stems from insufficient Vitamin D levels
Question #30: First-Line Treatment for Primary Hyperparathyroidism
- The preferred way is surgical removal because this can effectively treat both complications and symptoms
Question #31: Diagnosing Parathyroid Adenoma
- The best diagnostic tool is a neck-ultrasound.
Question #32: Treating Secondary Hyperparathyroidism
- In cases of secondary hyperparathyroidism, decreased level of Vitamin D. So medical therapy (Vitamin D) is the right treatment.
Question #33: Causes of Primary Hypoparathyroidism
- Autoimmune syndrome and Thyroid surgery complications
Question #34: Biochemical Findings in hypoparathyroidism
- Pathological biochemical finding include low active D levels, hypocalcemia, hypoPTH
- PTH stimulates the activity of 1-alpha-hydroxylase which produces calcitriol which is in the active form of Vitamin D. The details is 1alpha-hydroxylase converts 25-hydroxyvitamin D into the final product.
Question #35: Hypoparathyroidism and Paresthesia
- Paresthesia (abnormal sensation such as numbness and tingling) and asthenia (weakness) are consistent with hypoparathyroidism
Question #36: Question #37
- Primary hypoparathyroidism results in low levels of parathyroid hormone (PTH)
- Low PTH leads to decreased calcium absorption in the intestines and decreased calcium reabsorption from the kidneys.
- First-line treatments aim to maintain serum calcium levels within the normal range and prevent symptoms of hypocalcemia.
- Calcium supplementation helps to increase serum calcium levels
- Active vitamin D (calcitriol) supplementation is essential because it bypasses the impaired conversion of inactive vitamin D to its active form in the kidneys
- Calcitriol increases intestinal absorption of calcium and phosphorus and promotes bone mineralization.
- Because patients with primary hypoparathyroidism have impaired renal conversion of inactive vitamin D to its active form,
- Inactive vitamin D supplementation alone wouldn't be sufficient
- Similiarly, calcium supplementation alone wouldn't be sufficient to correct the underlying problem of impaired calcium absorption and bone mineralization.
Clinical Case #1: Post-Thyroidectomy
- Hypoparathyroidism occurs following total thyroidectomy because the parathyroid glands tend to be accidentally being injured/removed during surgery; causing a low PTH (parathyroid hormone).
- If this is suspected, we can proceed by evaluating calcium and PTH levels.
- Autoimmune hypoparathyroidism is associated with autoimmune polyendocrine syndrome type 1 (APS-1): APECED, adrenal Insufficiency, Mucocutaneous candidiasis
Clinical Case #2
- Testosterone can be mildly increased, and 17-OH progesterone can also be increased. Normal levels of progesterone usually are around 1ng/mL
- Oligomenorrhea is an infrequent cycle >35 days
- Congenital adrenal hyperplasia results in elevated 17-OH progesterone and mild androgen increases, so important to look at 17-OH progesterone especially when looking for connatal angdenal hyperplasia.
- When inquiring about hormone problems, the hormones need to be evaluated in the early follicleal stage
Clinical case #3
- For a DXA to show that a patient has Osteoporosis, the score needs to be <-2.5 SD
Clinical Exercises #2: Clinical Case 1 (Giacomo)
- Giacomo is a 58-year-old heavy smoker with a BMI of 32.8 Kg/m2 (obesity grade 1).
- He was diagnosed with hypertension and type 2 diabetes mellitus at age 44.
- He is treated with Ramipril 5 mg daily, Amlodipine 10mg daily, and basal-bolus insulin.
- He is being assessed for a recent detection of thyroid nodular hyperplasia.
- His wife is concerned about his deteriorating glycemic control, which is attributed to poor diet and therapy adherence.
- Thyroid ultrasound reveals a multi nodular thyroid goitre with hyper- and hypoechogenic nodules.
- The largest nodule is in the right lobe, measuring 2.5 x 1.8 cm, with irregular margins and internal microcalcifications.
- Blood tests show TSH near the low-normal range (0.5 mU/L), fT4 near the normal-lower range (9.8 pg/ml), and negative autoantibodies anti Tg and TPO.
- Evaluation of autoantibodies against thyroglobulin (Tg) and thyroid peroxidase (TPO) is crucial for diagnosing Hashimoto's Thyroiditis.
- Facial features should be considered, but not all individuals with these features will have the disease, as acromegaly is rare.
Giacomo's Medical Summary
- Obesity (5kg weight gain in the last year).
- Diabetes with worsening glycemic control.
- Arterial hypertension (mean home values 150-170/90-100).
Giacomo's Physical Examination Findings
- Weight: 92 kg, Height: 175 cm, BMI: 32.
- Arterial Pressure: 174/98, Heart rate: 96.
- Thoracic: wheezing and slight respiratory difficulties.
- Abdominal: marked abdominal adiposity.
- Thyroid: general size increase, especially on the right lobe.
- His facial appearance suggests possible acromegaly.
- Acral changes, alterations in the marginal/distal parts of the body, may be observable.
Question #1: Dental Abnormality
- The image shows increased dental diastasis/diastema.
Clinical Exercises 3: Clinical Case 1 (Sofia)
- Sofia is a 21-year-old non-smoker with a normal BMI and menarche at age 11
- She has no previous surgical treatments or comorbidities
- Her family history includes diabetes and hypothyroidism, particularly in her mother, but she is not following any chronic therapy
- Sofia reports marked asthenia and difficulty performing her usual scholar and sport activities, cold intolerance, hair loss, and a weight gain of 3 kg in 3 months
- She reports gynecological problems, specifically oligomenorrhea, and a gynecological visit did not detect pelvic alterations
- Physical exam findings include a heart rate of 54 bpm (bradycardia) and normal blood pressure (120/75 mmHg) with normal pulmonary and abdominal examinations
- Galactorrhea and hirsutism are absent, and her thyroid appears normal upon palpation
- Dermatologic findings include slight hair loss and eye folds
- Anamnestic findings include oligomenorrhea, asthenia, difficulty performing scholar and sport activities, cold intolerance, dermatologic findings, worsening constipation, slight weight gain, and a family history positive for hypothyroidism
- Oligomenorrhea is defined as menstrual cycles occurring at intervals of greater than 35 days
Clinical Exercises 3: Sofia's Diagnosis Plan
- In Sofia's case, there is no need to perform a thyroid ultrasound before evaluating hormone levels, and a pituitary MRI is not warranted without previous blood examinations
- Initially, pituitary, thyroid, and gonadal functions along with general blood evaluations should be requested
Clinical Exercises 3: Sofia's Laboratory Findings and Possible Diagnoses
- Lab results show increased Prolactin, normal LH/FSH/Cortisol/ACTH/17 OH Progesterone/Total Testosterone, increased TSH, reduced fT4, and normal blood exams/hepatic function/kidney function/glucose levels
- The most important values for the diagnosis are increased prolactin levels, increased TSH, and reduced fT4
- The reference range for LH depends on the phase of the menstrual cycle, but it is usually below 10-20 IU/L during the follicular phase
- Diagnoses include clinical hypothyroidism, subclinical hypothyroidism and slight hyperprolactinemia and clinical hypothyroidism and slight hyperprolactinemia
Clinical Exercises 3: Hypothyroidism vs Subclinical Hypothyroidism
- Clinical hypothyroidism is diagnosed based on biochemical findings (increased TSH and decreased fT4), not symptoms
- In subclinical hypothyroidism, only TSH is abnormal and increased
Clinical Exercises 3: Potential Etiological Causes of Hyperprolactinemia
- Potential causes include prolactinoma, hypothyroidism, hypopituitarism and venepuncture stress and PRL-secreting pituitary microadenoma
Clinical Exercises 3: Hypothyroidism Related to Hyperprolactinemia
- Hypothyroidism can cause slight hyperprolactinemia because TRH has a positive feedback on prolactin
- The main role of TRH is to stimulate thyrotrophic cells in the anterior pituitary gland to produce TSH and has a minor effect on lactotrophic cells, stimulating them to secrete prolactin
- Problems with the thyroid gland can cause a compensatory response of increased TSH and TRH, leading to increased stimulation of lactotrophic cells
- This is especially seen in patients affected by secondary or tertiary hypothyroidism, which are rarer than primary hypothyroidism
Clinical Exercises 3: Useful Diagnostic Examinations
- Useful diagnostic examinations include thyroid US, pituitary MRI, autoantibodies anti-thyroid gland evaluation, and thyroid US, or just autoantibodies anti-thyroid gland evaluation
- Thyroid ultrasound can support diagnosis, as autoantibodies can be negative in rare cases
Clinical Exercises 3: Autoantibodies
- Relevant autoantibodies include anti-thyroid peroxidase, anti-TSH receptor, anti-thyroglobulin and thyroglobulin antibodies
- Thyroglobulin is not evaluated in healthy subjects as it primarily aids with total thyroidectomy post thyroid carcinoma
Clinical Exercises 3: Thyroid US Features
- Nodular hyperplasia, heterogenous gland echotexture, diffuse gland enlargement and marked increased vascularization, and single hypervascularized nodules can be seen on the thyroid US, though nodular lesions and any thyroid enlargement are not seen in all patients with hypothyroidism
Clinical Exercises 3: Vascularization and Hyperthyroidism
- Vascularization is directly correlated with the functionality of the gland, with increased vascularization typically seen in hyperthyroidism
Clinical Exercises 3: Clinical Case 1 Follow-Up
- Sofia has positive anti-thyroid peroxidase and anti-thyroglobulin autoantibodies
- The ultrasound reveals a heterogeneous echotexture with pseudo-micronodules and cystic nodules with normal vascularization
- Diagnosis is autoimmune thyroiditis leading to clinical hypothyroidism
Clinical Exercises 3: First-Line Treatment for Sofia
- The first-line treatment for Sofia is medical therapy with Levothyroxine
Clinical Exercises 3: Sofia's Eutirox Treatment Results
- After two months of Eutirox, TSH is significantly suppressed at 0.05, and fT4 is elevated at 21 pg/mL
Clinical Exercises 3: Thyrotoxicosis vs Hyperthyroidism
- Thyrotoxicosis is increased circulating thyroid hormones
- Hyperthyroidism is a hyperfunctioning of the thyrotoxicosis
Clinical Exercises 3: Sofia's Treatment Plan
- Iatrogenic thyrotoxicosis is the diagnosis, so the dose of Eutirox needs to be reduced
- Two more months on Eutirox results in a TSH of 13 and fT4 of 8.1 pg/mL, so the dosage of Eutirox needs to be increased, because the TSH is increased and the fT4 is still low again
Clinical Exercises 3: Future Pregnancy and First-line Intervention
- Thyroid function must be strictly monitored, and an increase of Eutirox may be necessary during a pregnancy, because thyroid function increases to support hormonal requirements of mom and fetus
Clinical Exercises 3: Clinical Case 2 (Giovanni)
- Giovanni is a 78-year-old with cardiovascular disease and atrial fibrillation
- Routine blood work showed TSH at 6.8 and fT4 at 12.1 pg/mL
- Ultrasound showed a multinodular goiter with benign characteristics, and positive anti-thyroid gland antibodies
- The diagnosis is likely Hashimoto's thyroiditis leading to subclinical hypothyroidism
Clinical Exercises 3: First-Line Treatment for Giovanni
- Monitoring thyroid function and medical therapy with iodine and selenium supplementation is the desirable approach
Clinical Exercises 3: Elderly Patients and Hashimoto's Thyroiditis
- With an older patient with cardiac problems with not severe and without symptoms, there is not urgency to prescribe any treatment and not all patients with subclinical or clinical hypothyroidism need a treatment plan
Clinical Exercises 3: Amiodarone
- Amiodarone could be a factor but it is not known if this is the cause of hypothyroidism
Clinical Exercises 3: Clinical Case 3 (Eva)
- Eva is a 38-year-old smoker with a normal BMI and a family history of hypothyroidism
- She presents with oligomenorrhea, palpitations, insomnia, cold intolerance, hair loss, ocular pain, diarrhea, and weight loss
- Cardiac examination shows increased systolic pressure and bradycardia with increased differential pressure.
- She also has hot, dry skin and exophthalmos, but normal pulmonary and abdominal examinations with no galactorrhea or hirsutism
Clinical Exercises 3: Eva's Medical Data
- PRL, LH, FSH, Cortisol, and ACTH levels are all normal
- TSH is decreased, while fT4 is increased, and it needs to be known if the T4 is typical for thyrotoxicosis to conclude clinical hypertyroidism
Clinical Exercises 3: Eva's Differential Diagnoses
- Subclinical hyperthyroidism and subclinical/clinical thyrotoxicosis are possible
Clinical Exercises 3: Clinical Case 3 Next Steps
- A thyroid ultrasound and evaluation of autoantibodies are recommended
- Other than the evaluation of autoantibodies, it is important to evaluate the neck
Clinical Exercises 3: Thyroid Ultrasound Possible Findings
- Possible findings include nodular hyperplasia, heterogenous gland echotexture, diffuse gland enlargement and marked increased vascularization, and single hypervascularized nodule
Clinical Exercises 3: Thyroid Vascularization
- High vascularization indicates thyroid hyperfunctioning
Clinical Exercises 3: Clinical Case 3 Final Diagnosis
- Eva is positive for anti-TSH receptor autoantibodies (TRAb), associated with Graves' disease
- A thyroid ultrasound showed an enlarged thyroid with a heterogenous echotexture, hypoechoic pseudo-micronodules, cystic nodules, and increased vascularization
- Her diagnosis is Graves' disease leading to clinical hyperthyroidism
Clinical Exercises 3: Ocular Implications in the Diagnosis
- Ocular MRI and neuro-ophthalmologic visit recommended
- Exophthalmos can be present in all cases of thyrotoxicosis
Clinical Exercises 3: Clinical Case 3 Next Steps in Treatment
- Medical therapy with Thioamides is recommended, and corticosteroids may be added for ocular involvement
- Propranolol can be used to reduce symptoms and decrease activation of fT4 to fT3 in circulation
- Corticosteroids are the main treatment for Graves' ophthalmopathy
Clinical Exercises 3: Thioamide Treatment, Methimazole vs Propylthiouracil
- Methimazole (Tapazole) is the first-line treatment for Graves' hyperthyroidism due to its effectiveness and fewer side effects than Propylthiouracil
- Propylthiouracil is second-line and used when a patient is pregnant or Methimazole is causing side effects
Clinical Exercises 3: Methimazole Side Effects
- All of the above (Agranulocytosis, toxic hepatitis, and teratogenic effects)
Clinical Exercises 3: Long-Term Treatment Goals
- Normal TSH levels, while also checking on anti-TSH receptor autoantibodies
- Reducing, not stopping is also the goal to avoid relapse
Clinical Exercises 3: Clinical Case Treatment Length and Process
- Thyrostatic, and lasts 12-24 months to effectively treat thyroid function and autoimmune condition with methimazole
- Methimazole needs to be progressively reduced
Clinical Exercises 3: Clinical Case 4 (Aldo)
- Aldo, 41, presents with neck swelling, marked migraine pain, and a sore throat/mild fever two to three weeks prior
- He also has tachycardia, palpitations, insomnia, general sickness, and a low-grade fever
- Blood tests show TSH at 0.005 and fT4 at 18.9 pg/mL
Biochemical Analysis
- T4 is within upper normal reference range, it is clinical toxicosis
Clinical Exercises 3: Clinical Case 4 Diagnosis and Pathophysiology
- To exclude Graves’ disease, autoantibodies need to be evaluated and Thyroid scintigraphy is also
Thyroid Scintigraphy
- Higher iodine uptake, instead when there is a subacute thyroiditis there is damage, which leads to a decreased iodine uptake
Clinical Exercises 3: Clinical Case 4 Thyroid Findings
- Negative anti-TSH receptor, anti-thyroperoxidase, and thyroglobulin autoantibodies
- Thyroid scintigraphy shows an enlarged thyroid gland with a heterogeneous echotexture, hypoechoic pseudo-micronodules and cystic nodules
Clinical Exercises 3: Clinical Case 4 Result
- Subacute thyroiditis leading to clinical thyrotoxicosis, and not hyperthyroidism is associated
- The increased levels of hormones are being caused by structure not by hyperfunctioning
Treatment
- Anti-inflammatory is the first line, when effective. If not then beta blockers for short term help, methamizole is bad for this condition
- Effective when only hyperfunctioning
Clinical Exercises 3: Clinical Case 5 Giovanna's Nodule
- Hypoechogenic with irregular margins, microcalcifications and internal, peripheral vascularization
- Probably malignent must do FNAC or Fine-Needle Aspiration
Clinical Exercises 3: FNAC
- Classification is important TIR4 is for surgical evaluation
- If its TIR1 repeat exam because it is not diagnostic
- TIR 2 is proceed with follow up
- TIR 3a is intermediate and 10% risk
- TIR 3b is intermediate 30%
Clinical Exercises 3: Surgical Results
- Hypoparathyroidsim is the most frequent result in surgeries
Clinical Exercises 3: Solid and Hypo-echoic Results
- FNAC should be considered in small leisons, if cut off 7-8mm
Clinical Exercises 3: Bigger solid-ish masses
- Bening noduel because of solid part
- FNAC is performed and classified TIR2
Clinical Exercises 3: Case 6 Francessco
- presents with tachycardia and mild heart palpitations, he exhibits sub clinical thyrotoxicosis, normal FT4 and TSH,
- Nodule, isoechogenic, normal margins increased vascularlization
More notes from Case 6
- Perform a thyroid scintigraphy because that is mandatory
- Picture with results are hyperuptake
- Plummer and a toxic adenoma which are synonymous so C
- Start with methimazole and beta blockers to reduce hyperfuncntioning then surgery
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