| Screening for Hypothyroidism, recommendations of the American Thyroid
Association (ATA): All adults over 35 yo, every 5 yrs (younger if FHx or
autoimmune disease, e.g., Type 1 DM)
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2003 Thyroid Tidbits and Recert Review sans Evidence
1. 24 year old man with large 3 x 3 cm firm thyroid nodule noted
a few months ago complains of severe diarrhea. T4 = 6.0 TSH = 3.0
Calcium 13.0 Phosphorus 2.0 Family history includes sudden death
of his father during gall bladder surgery at age 45. On examination
the patient also has elevated BP 160/100 and resting tachycardia.
Which of the following apply:
a) Might have medullary thyroid cancer
b) Might have elevated calcitonin level
c) Might have MEN 2A
d) Blood for RET proto-oncogene analysis might help confirm
diagnosis and be used to screen rest of his family
e) All of the above
2. 24 year old man with large 3 x 3 cm firm thyroid nodule,
no symptoms; T4 11.0 TSH < 0.003 Scan: Uptake only in the
nodule. Which of the following apply:
a) This is a "hot" nodule, and virtually certainly benign
b) Since the normal thyroid tissue is suppressed, I-131
treatment should destroy only the hot nodule and leave
the patient euthyroid in the long run
3. Patient on 1S is on Li++ for several years. Now more lethargic
than usual and complains of polyuria and polydipsia. You
should entertain checking which of the following:
a) TFTs, including TSH
b) calcium
c) urinary concentraing ability
d) All of the above
4. Patient followed by Neurology, on Dilantin for several years.
T4 = 4 fT4 = slightly low TSH = 3.0 Albumin = 4.0
Calcium = 7.5 Phosphorus = 1.5 Which of the following apply:
a) Dilantin can lower T4 by unknown mechanism, but patient is
euthyroid
b) Dilantin can cause vitamin D deficiency, causing low
calcium and low phosphorus (and elevated PTH)
c) It's a good idea to prescribe daily multivit to pts on DPH
d) All of the above
5. 24 year old man with asymptomatic 3 x 3 firm thyroid nodule,
slightly "cool" on scan, solid on sonogram. Calcium and phosphorus
are WNL. T4 = 8.0 TSH = 3.0 Which of the following apply:
a) Should check calcitonin level
b) Should check RET proto-oncogene
c) Should give trial of thyroid hormone suppression
d) Should send for biopsy
e) Should send for surgery
6. Patient with hepatitis C treated with interferon develops
some tenderness in region of an enlarged, firm thyroid.
T4 = 15 free T4 elevated TSH < 0.003. Thyroid scan
shows virtually no uptake at 24 hours. Sonogram reveals
enlarged gland with heterogeneous texture, but no focal
abnormalities. Which of the following apply:
a) Patient is probably taking Synthroid
b) Patient probably has "struma ovarii"
c) Patient has atypical Graves' disease
d) Patient has developed subacute thyroiditis
7. A 24 year old woman is 1 1/2 months pregnant and complains of
anorexia, nausea, vomiting. Ob/Gyn finds TSH < 0.03
T4 = 14 free T4 = WNL T3 total WNL. You should:
a) Send for thyroid scan and uptake to exclude thyroiditis
b) Treat with PTU or Tapazole while monitoring LFTs, TFTs,
BUN, warn about arthritis and agranulocytosis
c) Serial observation of TFTs [*see screening handout*]
8. A 50 year old man with a 15 year history of diabetes is admitted
with a difficult to treat foot ulcer. On admission, the TSH = 2.0
He has a small goiter. After 5 weeks of treatment, including
debridement and daily soaks with Betadine, the ulcer has almost
healed, and the TSH is = 120.0
a) What happened?
b) How would you treat him?
9. A 50 year old man is admitted for chest pain which resolves with
medical treatment. There is no evidence of MI. He has a small
goiter. TSH = 2.0 Coronary angiogram shows non-stentable
disease. His HMO acquiesces to bypass surgery in 1 month. On
readmission he is in atrial fibrillation. T4 = 12, TSH < 0.03
T3 Total = 300 (nl 80-180).
a) What happened?
b) How would you treat him?
10. A 50 yo old man is admitted for atrial fibrillation. TSH = 3.0
He is controlled with Amiodarone. Three months later he is
admitted with T4 < 1.0 TSH = 150, hyponatremia, hypothermia,
hypotension, low voltage on EKG
a) What happened?
b) How do you treat him?
c) He wants to know what to do if Indian Point melts down.
[*see DOH/Med Let Handout*]
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