1. ABSITE REVIEW Thyroid/Parathyroid
David Grossman M.D.
12/4/06

2. What is the most common thyroid abnormality in hospitalized patients with non thyroidal illness?
Low T3 concentrations

3. What percentage of T3 is derived from T4
80%

4. FNA of thyroid. Orphan any cells. What kind of thyroid cancer?
Papillary

5. What is the major thyroid hormone binding protein
Thyronine binding globulin (TBG)

6. What percentage of T4 and T3 are bound?
Greater than 99.5%

7. What is the major cause of a decreased T3 concentration in patients with a critical illness?
Impaired peripheral conversion of T4 to T3 secondary to inhibition of the deiodination process

8. What factors decrease TSH secretion?
Acute and chronic illness
Calorie restriction
Dopamine and dopamine agonists
Surgical stress
Minor decreases are associtated with carbamazapine, opiates, phenytoin, somatostatin

9. Mechanism of action of PTU
Prevents DIT, MIT coupling

10. Mechanism of action of prednisone? ( in terms of thyroid)
Blocks conversion of T4-T3

11. A patient with a history of radiation exposure as a child was found to have an enlarged lymph node on PE. The lymph node is removed and there is normal appearing thyroid tissue in the lymph node. What is the diagnosis?
Papillary Thyroid Cancer

12. What is the embryologic origin of the thyroid gland?
From median downgrowth of the first and second pharyngeal pouches in the area of the foramen cecum

13. What lab abnormality is associated with DeQuervain’s thyroiditis?
Elevated ESR
Can be associated with hyperthyroidism
PE/symptoms: Tender thyroid, sore throat, mass, weakness, fatigue
Treat with steroids/ASA

14. What genetic mutation is associated with medullary thyroid cancer?
Ret proto oncongene

15. What is the first test after H and P to evaluate a thyroid nodule?
FNA

16. Can radioactive iodine be safely given during pregnancy?No

17. True or False: Cardiac output is decreased in hypothyroidism

18. What are the hemodynamics of a thyroid storm?
Tachychardia
Increased Cardiac output
Decreased SVR

19. What muscle is not innervated by the recurrent laryngeal nerve?
Cricothyroid
Cricothyroid is innervated by?
Superior laryngeal nerve

20. All the parathyroids typically receive their blood supply from what artery?
Inferior thyroid arteries

21. What bone finding is pathognomonic finding for hyperparathyroidism?
Osteitis fibrosa cystica

22. False: Solitary parathyroid adenoma is the most common etiology
True or False: Hyperparathyroid is most commonly associated with 4 gland hyperplasia?
False: Solitary parathyroid adenoma is the most common etiology

23. What are the 4 opthalmologic signs of hyperthyroidism?
Exopthalmos
Lid lag
Lid retraction
Periorbital swelling

24. What is the initial treatment of thyroid storm?
IV fluids
Propranalol
PTU
Iodine
Hyothermia

25. What are the CNS manifestations of myxedema?
Depression
Memory loss
Ataxia
Frank psychosis
Myxedema
Coma

26. Why is the pulse pressure wide in patients with thyrotoxicosis?
Increased blood flow and vasodilation

27. Causes of Hypercalcemia
PTH
Adrenal insufficiency
Multiple Myeloma
Pagets disease
Sarcoidosis
Cancer
Hyperthyroidism/Hypothyroidism
Milk Alkali
Immobilization
D Vitamin D/A excess
Thiazide Diuretics

28. A 45 y/o female presents with a 2 year history of diffuse, tender thyroid enlargement, lethargy and 20 pound weight gain. What is the most likely diagnosis?
Hashimotos thyroiditis
What is the treatment?
Thryoid replacement therapy

29. What is the appropriate treatment for patients with thyroglossal duct cysts?
Excision of the entire cyst, as well as the thyroglossal tract to its origin, at the foramen cecum, including the central portion of the hyoid bone

30. What is the venous drainage of the thyroid gland?
The superior and middle thyroid veins drain into the internal jugular vein and the inferior thyroid vein drains into the innominate vein

31. What is the result of injury to the recurrent laryngeal nerve?
Hoarseness

32. What is the most common location of the recurrent laryngeal nerve?
The tracheoesophageal groove

33. What is the definitive, non-surgical treatment of graves disease?
I31-I radioablation

34. What are the indications for surgical treatment of Graves disease?
Extremely large glands, presence of nodules, women of childbearing age and patients who are opposed to radioiodine

35. Follicular carcinoma metastases occur primarily by what route?
Hematogenous dissemination to the lungs, bones and other peripheral tissues

36. How is the pathologic diagnosis of follicular thyroid carcinoma confirmed?
Identification of vascular or capsular invasion by the tumor from histologic sections

37. True or False: Exposure to low-dose radiation therapy is considered a risk factor for thyroid carcinoma?
True

38. What are the histiochemical characteristics of medullary thyroid carcinoma
Congo red dye positive
Apple-green birefringence consistent with amyloid
Immunohistochemistry positive for cytokeratins, CEA and calcitonin

39. What is the embryological origin of the parathyroid glands?
The inferior parathyroid glands originate from the third pharyngeal pouch
The Superior parathyroid glands originate from the fourth pharyngeal pouch

40. Loss of high pitched voice
What voice problem will a patient have if there is injury to external branch of superior laryngeal nerve?
Loss of high pitched voice

41. Recurrent laryngeal nerve supplies all laryngeal muscles except the cricothyroid which is supplied by
Superior laryngeal nerve
On the right the RLN goes around
The right subclavean artery
On the left the RLN goes around the arch of the aorta

42. True or false: The presence of follicular cells can be used to differentiate between benign and malignant
False

43. Which thyroid cancer has the best prognosis?
Papillary

44. Which thyroid cancer is associated with MEN II
Medullary

45. Which thyroid cancer is associated with psammoma bodies?
Papillary

46. FNA of nodule reveals amyloidosis. Which thyroid cancer?
Medullary thyroid carcinoma

47. What percent of individuals with lingual thyroids have no other thyroid tissue?
70%

48. Calcium 9-11, normal PTH, low urinary Ca
What are the lab values in patients with Familial Hypercalcemic Hypocalciuria?
Calcium 9-11, normal PTH, low urinary Ca
Caused by a defect in the PTH receptor in the distal convoluted tubule that causes increased absorption of Ca
Treatment: nothing, no parathyroidectomy

49. Re-opening of cervical wound
Twelve hours after having undergone a subtotal thyroidectomy, a 30 y/o woman develops agitation and difficulty breathing. Exam reveals tachychardia, anterior cervical swelling. Dressing is dry. The most appropriate treatement is
A. insertion of ET tube
Re-opening of cervical wound
Determination of the serum Calcium and magnesium concentrations
Administration of morphine
Administration of oxygen by nasal cannula

50. What are the components of MEN I syndrome?
Parathyroid hyperplasia
Islet cell neoplasms
Pituitary tumors

51. What is the surgical treatment of choice for patients with secondary hyperparathyroidism?
Subtotal (3 and ½) parathyroidectomy or total parathyroidectomy with autotransplantation

52. Where is calcitonin produced?
In the parafollicular cells( c-cells) of the thyroid

53. A patient with MTC has a high urinary VMA and an enlarged left adrenal gland. What is the next step in management?
Medical management with alpha and beta blockers, if necessary, followed by resection of the left adrenal gland. This should be performed before the thyroid surgery

54. What are the indications for adjuvant thyroid hormone in patients with well differentiated thyroid carcinoma?
All patients with well differentiated carcinoma should be treated with thyroid hormone to suppress TSH for life, regardless of the extent of surgery

55. What is the treatment of anaplastic thyroid cancer?
Combination of chemo/radiation
Adriamycin is best single chemo agent

56. MTC associated with MEN IIa. At what age do you perform thyroidectomy?
Total thyroidectomy by age 5

57. MTC associated with MEN IIb. At what age do you perform thyroidectomy?
Prophylactic total thyroidectomy by age 2

58. Hyperparathyroidism is associated with what gene?
Prad

59. What is the treatment of Hypercalcemic Crisis?
Fluids, furosemide, dialysis

60. Parathyroid adencarcinoma
A patient in the hospital is noted to have a very high calcium and a palpable rock hard neck mass. What is your diagnosis?
Parathyroid adencarcinoma

61. What is the treatment for parathyroid Cancer?
Wide en bloc excision and ipsiltateral thyroidectomy
Recurrence about 50%
Most common location for metastasis: LUNG

62. What is the single most important test in the diagnostic work-up of a patient with a solitary thyroid nodule?
FNA

63. What factor best correlates with the presence of lymph node metastases in papillary carcinoma?
Age

64. What is the Cl to phos ratio in Hyperparathyroidism?
Cl/Phos ratio is > 33

65. Most common location for the missing gland is normal anatomic position
At reoperation for a missing parathyroid gland, what is the most common location for the missing gland?
Most common location for the missing gland is normal anatomic position

66. What is the Wolff-Chaikoff effect?
High Iodine doses inhibits TSH

67. What is the major complication (side effect) of PTU?
Aplastic anemia
Do not use in pregnancy-crosses the placenta- causes cretinism