Snapshot A 27-year-old woman with vitiligo presents to her primary care physician with progressive fatigue and weight loss despite a good appetite. On exam, her blood pressure is 170/110 mmHg, pulse is 110/min, diaphoretic, displays brisk reflexes, and has bilateral exophthalmos. Introduction Clinical definition autoimmune hyperthyroidism Genetics HLA-DRB1 and HLA-DQB1 PTNP22 Associated conditions polyglandular autoimmune syndrome pernicious anemia vitiligo diabetes Epidemiology Demographics the most common cause of hyperthyroidism in the United States female dominant typically 20-40 years of age ETIOLOGY Pathogenesis triggered by stress e.g. childbirth, infection, steroid withdrawal, and trauma to the thyroid stimulating autoantibodies against the TSH receptor leading to the overproduction of thyroid hormone type II hypersensitivity pituitary TSH is suppressed via negative feedback from elevated thyroid hormone Presentation Symptoms tachycardia and/or palpitations thyroid hormone increases heart rate and contractility and decreases systemic vascular resistance fatigue and muscle weakness weight loss hyperactivity and/or tremulousness diarrhea warm moist skin and sweating heat intolerance eye pain and/or double vision Physical exam hypertension and/or arrhythmias enlargement ophthalmopathy (proptosis and exophthalmos) the hallmark of Graves disease but not always present often worsens after radioiodine ablation symmetrical, non-tender thyroid enlargement myxedema dermal accumulation of mucopolysaccharides non-pitting hyperreflexia imaging Radioactive iodine (123I) thyroid scan contraindicated in pregnancy defer to autoantibody assays Computed tomography (CT) scan or magnetic resonance image (MRI) of the orbits evaluation of ophthalmopathy Studies Diagnostic testing diagnostic approach screening for patients with clinical suspicion autoantibody titers are diagnostic imaging to differentiate etiologies of hyperthyroidism ancillary laboratory tests for associated dysregulation studies TSH level initial test of choice thyroid hormone level start with T4 level (total or free) if T4 level is normal, T3 level may be helpful autoantibody assays anti-TSH antibodies are almost always positive diagnostic for Graves complete blood count would demonstrate associated normocytic anemia, low-normal leukocytes, and low-normal platelets lipid profile would demonstrate associated low total cholesterol and triglyceride biopsy not routinely indicated but would show lymphocytic infiltrates and follicular hypertrophy Differential Multinodular toxic goiter distinguishing factors patchy uptake on 123I thyroid scan more common in elderly patients Toxic thyroid adenoma distinguishing factor single nodule with uptake on 123I thyroid scan Iatrogenic distinguishing factors excessive levothyroxine intake no increase in uptake on 123I thyroid scan DIAGNOSIS Diagnostic criteria ↓ TSH and ↑ T4 if T4 is normal, then possibly ↑ T3 positive anti-TSH antibodies radioactive iodine (123I) thyroid scan diffusely increased uptake differentiates Graves from other etiologies of hyperthyroidism Treatment Medical treatment first-line propranolol indication sympathetic symptoms such as palpitations, muscle weakness, and/or anxiety wean when thionamides take effect not definitive treatment indicated for atrial fibrillation secondary to hyperthyroidism (metoprolol) second-line thionamides methimazole and propylthiouracil mechanism inhibits thyroid hormone synthesis indication propylthiouracil during pregnancy adverse effects agranulocytosis discontinue and obtain CBC with differential if any signs of infection hepatotoxicity long-term remission in a minority of patients not definitive treatment third-line radioiodine ablation (131I) most common treatment definitive treatment mechanism destruction of thyroid follicular cells patients transition to hypothryoidism 3-6 months post-ablation, and subsequently require life-long thyroid replacement medication release of thyroid hormone secondary to destruction may lead to a transient worsening of symptoms pretreat with glucocorticoids indication failed antithyroid drugs contraindication pregnancy and breastfeeding Surgical treatment thyroidectomy indication cannot tolerate medical therapy pregnancy allergy very large goiter Special considerations pregnancy propranolol propylthiouracil thyroidectomy ophthalmopathy steroids surgical decompression orbital radiation Complications Life-threatening thyroid storm with fatal arrhythmia Pregnancy complications anti-TSH receptor antibodies may cross placenta and lead to fetal hyperthyroidism cretinism from contraindicated radioiodine ablation Thyroidectomy complications hypothyroidism laryngeal nerve palsy hypoparathyroidism and hypocalcemia ‘
QUESTIONS 1 of 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.EC.17.4723) A 35-year-old homeless woman presents to the emergency department complaining of a strange sensation in her chest. The patient is disheveled and dirty. The patient is an immigrant and does not speak English. On physical exam you note a sweaty and nervous woman who demonstrates a mild tremor and proptosis. Her pulse is 110/minute, temperature is 99°F (37.3°C), and blood pressure is 110/70 mmHg. IV fluids are started. An EKG is performed and the findings are shown in Figure A. Initial labs are drawn and pending. A urine toxicology returns negative for testable illicit substances. Which of the following is the next best step in management? QID: 108521 FIGURES: A Type & Select Correct Answer 1 Vagal maneuvers 26% (18/70) 2 Adenosine 3% (2/70) 3 Propranolol 57% (40/70) 4 Propylthiuracil 6% (4/70) 5 Synchronized cardioversion 7% (5/70) M 7 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M2.EC.17.4728) A 26-year-old G1P0 presents to her first obstetric visit after having a positive urine pregnancy test at home. Her last menstrual period was 9 weeks ago. She has no past medical history, but her mother has rheumatoid arthritis. The patient states that for several weeks, she has felt especially warm, even when her co-workers do not, and had muscle weakness. She also complains of mood swings and fatigue. At this visit, her temperature is 99.0°F (37.2°C), blood pressure is 140/81 mmHg, pulse is 106/min, and respirations are 17/min. Physical exam is notable for 3+ deep tendon reflexes bilaterally and 4/5 strength in both hips and shoulders. Ultrasound confirms the presence of a heart beat and shows a crown rump length that is consistent with a gestational age of 9 weeks and 3 days. Which of the following is the best therapy for this patient? QID: 108592 Type & Select Correct Answer 1 Radioactive thyroid ablation (I-31) 4% (3/72) 2 Methimazole 15% (11/72) 3 Propylthiouracil 71% (51/72) 4 Prednisone 3% (2/72) 5 Intravenous immunoglobulin 3% (2/72) M 7 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.EC.16.4694) A 40-year-old woman with a past medical history significant for pernicious anemia and vitiligo presents to the physician with the chief complaints of heat intolerance and frequent palpitations. The patient does not take birth control and her urine pregnancy test is negative today. Physical exam reveals a patient that is hyper-reflexive with a non-tender symmetrically enlarged thyroid gland. You order thyroid function tests for workup. What thyroid function values are most expected? QID: 107868 Type & Select Correct Answer 1 T4 elevated, free T4 normal, T3 elevated, thyroid stimulating hormone (TSH) normal 9% (1/11) 2 T4 elevated, free T4 elevated, T3 elevated, TSH elevated 0% (0/11) 3 T4 elevated, free T4 elevated, T3 elevated, TSH decreased 91% (10/11) 4 T4 decreased, free T4 decreased, T3 decreased, TSH decreased 0% (0/11) 5 T4 normal, free T4 normal, T3 normal, TSH elevated 0% (0/11) M 6 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M3.EC.15.5) A 32-year-old woman presents to the emergency department with a 1-month history of heat intolerance, a racing heart, unintentional 4-pound weight loss, and sweating. She states she is generally healthy and only takes a multivitamin. Her temperature is 100°F (37.8°C), blood pressure is 122/82 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 100% on room air. Physical exam is notable for a nontender and enlarged thyroid. HEENT exam is notable for the finding in Figure A which is mild. The patient's urine hCG is negative. Laboratory values are notable for a TSH of 0.1 mIU/L. What is the most appropriate definitive treatment for this patient? QID: 102723 FIGURES: A Type & Select Correct Answer 1 No treatment is indicated 0% (0/19) 2 Propranolol 0% (0/19) 3 Propylthiouracil 42% (8/19) 4 Radioactive iodine 42% (8/19) 5 Thyroidectomy 11% (2/19) M 11 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.EC.15.4423) A 34-year-old woman presents to her primary care physician with insomnia. She notes that she has had difficulty calming down for the past several months. She also reports feeling warm, even when others feel cold, and that her eyes appear to bulge more than she remembered (Figure A). Her TSH is found to be 0.03 mcU/mL (nl 0.4-2.5 mcU/mL), and free T4 is 5 ng/dl (nl 0.7-1.9 ng/dl). She chooses to undergo radioiodine ablation, and returns to her physician 2 days after the procedure noting increased bulging of her eyes. Which of the following steps could have decreased the risk of this complication? QID: 106987 FIGURES: A Type & Select Correct Answer 1 Pretreatment with a non-steroidal anti-inflammatory drug (NSAID) 0% (0/35) 2 Pretreatment with a beta blocker 17% (6/35) 3 Pretreatment with furosemide 0% (0/35) 4 Pretreatment with prednisone 71% (25/35) 5 Post-treatment with levothyroxine immediately after ablation 9% (3/35) M 7 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.EC.14.75) A 66-year-old man presents to the emergency department with palpitations. He has a history of hypertension and diabetes. His temperature is 97.6°F (36.4°C), blood pressure is 154/100 mmHg, pulse is 122/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, the patient is mentating normally and is in no acute distress. An ECG is performed as seen in Figure A. Initial laboratory studies including a CBC, serum chemistries, and 2 troponins are unremarkable. What is the most appropriate next step in management? QID: 104081 FIGURES: A Type & Select Correct Answer 1 Amiodarone 17% (3/18) 2 Cardioversion 17% (3/18) 3 Digoxin 22% (4/18) 4 Labetalol 6% (1/18) 5 Metoprolol 39% (7/18) M 7 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (M2.OMB.4878) A 30-year-old woman presents to the emergency department for palpitations. For 2 months, she has experienced intermittent palpitations along with menstrual irregularity and hair loss. At home, the air conditioner is at its coldest setting, but the patient still feels overheated. Her temperature is 99.5°F (37.5°C), blood pressure is 135/90 mmHg, pulse is 120/min, and respirations are 22/min. The patient is diaphoretic with tremulous hands, demonstrates thyromegaly, and protrusion of her eyes is noted. She is given atenolol in the emergency department with improvement of her palpitations and is instructed to follow up with her primary doctor for further management. Which of the following is most likely to be found in this patient after definitive treatment of her condition? QID: 216266 Type & Select Correct Answer 1 Exophthalmos 0% (0/0) 2 Hair loss 0% (0/0) 3 Heat intolerance 0% (0/0) 4 Menstrual irregularity 0% (0/0) 5 Thyromegaly 0% (0/0) M 12 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (0) Endocrine | Graves Disease Endocrine - Graves Disease Listen Now 22:7 min 6/22/2021 80 plays 5.0 (1)