rapid fire
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Rapid Fire. Blood supply to the thyroid?. Superior thyroid artery 1 st branch of external carotid Inferior thyroid artery From thyrocervical trunk Ima artery From innominate or aorta. The recurrent laryngeal nerve loops around what?. Right subclavian (sometimes innominate) - PowerPoint PPT PresentationTRANSCRIPT
Rapid Fire
Blood supply to the thyroid?Superior thyroid artery
1st branch of external carotid
Inferior thyroid arteryFrom thyrocervical trunk
Ima arteryFrom innominate or aorta
The recurrent laryngeal nerve loops around what?Right subclavian (sometimes innominate)
Aorta on left
If you find a non-recurrent nerve, which side is it more likely to be on?Right
Medications for treating hyperthyroidism? How do they work?PTU (propylthiouracil)
Inhibit peroxidases, preventing DIT & MIT couplingInhibits peripheral conversion of T4 to T3
MethimazoleInhibit peroxidases, preventing DIT & MIT coupling
Methimazole has longer half life, PTU is less likely to cross placenta
Most common cause of hypothyroidism?Hashimoto’s thyroiditis
Path: lymphocytic infiltrate
Enlarged, painless, chronic thyroiditis
Most common thyroid cancer?Papillary
Least aggressive, slow growing, best prognosis
Path: psammoma bodies, orphan annie nuclei
Thyroid cancer with hematogenous spread?Follicular
Spread to bone most common
More aggressive than papillary
Thyroid cancer associated with MEN?Medullary
Arise from parafollicular cells
Path: amyloid deposition
Gastrin causes increased calcitonin in medullary thyroid cancer
Treatment for medullary thyroid cancer?Total thyroidectomy with central neck dissection
Monitor disease recurrence with calcitonin
Clinically + lymph nodes – B/L MRND
MEN – proph thyroidectomy & central neck by age 2
Thyroid cancer with worst prognosis?Anaplastic
If resectable, do total thyroidectomy
Treatment for papillary thyroid cancer?<1cm – lobectomy
>1cm – total thyroidectomy
Special circumstances: Bilateral lesions, multicentricity, history of XRT, positive margins
Total thyroidectomy
I-131 – metastatic disease, residual local disease, +lymph nodes, capsular invasion
Treatment for follicular thyroid cancer?<1cm – lobectomy
>1cm – total thyroidectomy
I-131 for >1cm, extrathyroidal disease
Embryologic origin of parathyroids?Superior parathyroids
4th branchial pouch
Inferior parathyroids3rd branchial pouch
Blood supply to parathyroids?Inferior thyroid artery
Is PTH high or low in…primary hyperparathyroidism?secondary hyperparthyroidism?tertiary hyperparathyroidism?Primary
High
SecondaryLow
TertiaryHigh
Treatment of parathyroid cancer?En bloc resection – parathyroidectomy & ipsilateral thyroidectomy
Which adrenal vein goes directly into IVC?Right adrenal vein
In pheochromocytoma, what drug should be given preoperatively?Phenoxybenzamine
Alpha blocker
Do not give beta blocker before alpha blocker hypertensive crisis
What is produced by parafollicular cells?Calcitonin
What is the most sensitive indicator of thyroid function?TSH
What is the function of the recurrent laryngeal nerve?Motor to all muscle of larynx except cricopharyngeus
What is the most common cause of hypercortisolism?Iatrogenic
What is the most common endogenous (non-iatrogenic) cause of hypercortisolism?
Pituitary adenoma
What lab values are seen with primary hyperaldosteronism?Serum K low, urine K high
Serum Na high
Plasma renin low
Aldosterone:renin >20
What is the treatment for adrenocortical carcinoma?Radical adrenalectomy
Residual or recurrent disease Mitotane – treats endocrine symptoms, has caused tumor regression in some
What is the rate limiting step in catecholamine production?Tyrosine hydroxylase
What is the Rule of 10s?Pheochromocytoma
10% malignant10% bilateral 10% familial 10% extra-adrenal10% in children
What is MEN-1?Parathyroid hyperplasia
Pancreatic islet cell tumor
Pituitary adenoma
What is the most common pancreatic islet cell tumor in MEN-1?Gastrinoma
What is the most common pancreatic islet cell tumor overall?Insulinoma
What do you fix first in MEN-1?Parathyroid disease
What is MEN-2A?Parathyroid hyperplasia
Pheochromocytoma
Medullary thyroid cancer
What is MEN-2B?Pheochromocytoma
Medullary thyroid cancer
Mucosal neuromas
Marfanoid body habitus
What do you fix first in MEN-2A and 2B?Pheochromocytoma
What gene mutation is associated with MEN-1?MENIN gene
What gene mutation is associated with MEN-2?RET proto-oncogene
What labs values are seen with Familial Hypercalcemic Hypocaliuria?High serum Ca, low urine Ca
Urine Ca should be high in hyperparathyroidism
Normal PTH
Caused by defect in PTH receptor in distal convoluted tubule causing increased reabsorption of calcium
When do you do a parathyroidectomy for Familial Hypercalcemia Hypocalciuria?
Never
What are the layers of the adrenal cortex & what is produced by each?Zona glomerulosa
Mineralcorticoids (aldosterone)
Zona fasciculataGlucocorticoids
Zona reticularisAndrogens/estrogens
What ezyme converts norepinephrine to epinephrine? Where is it found?PMNT
Adrenal medulla and Organ of Zuckerkandl
The anatomic relationship of the parathyroid glands to the recurrent laryngeal nerve can be described as
A. Both the superior & inferior glands are posterolateral to the nerve
B. The superior glands are anteromedial and inferior glands are posterolateral to it
C. Both the superior & inferior glands are anteromedial to the nerve
D. The superior glands are posterolateral and inferior glands are anteromedial to it
E. The superior glands are posteromedial and inferior glands are anterolateral to it
The anatomic relationship of the parathyroid glands to the recurrent laryngeal nerve can be described as
A. Both the superior & inferior glands are posterolateral to the nerve
B. The superior glands are anteromedial and inferior glands are posterolateral to it
C. Both the superior & inferior glands are anteromedial to the nerve
D. The superior glands are posterolateral and inferior glands are anteromedial to it
E. The superior glands are posteromedial and inferior glands are anterolateral to it
A 63yo man has symptoms of Cushing’s syndrome. Labs show an elevated cortisol level with a slightly elevated plasma ACTH. A high dose dexamethasone suppression test shows suppression of ACTH and decreased cortisol. The condition most likely responsible is
A. Adrenal carcinoma
B. Pituitary adenoma
C. Ectopic ACTH producing tumor
D. Bilateral adrenal hyperplasia
E. Adrenal adenoma
A 63yo man has symptoms of Cushing’s syndrome. Labs show an elevated cortisol level with a slightly elevated plasma ACTH. A high dose dexamethasone suppression test shows suppression of ACTH and decreased cortisol. The condition most likely responsible is
A. Adrenal carcinoma
B. Pituitary adenoma
C. Ectopic ACTH producing tumor
D. Bilateral adrenal hyperplasia
E. Adrenal adenoma
Hypercortisolism – Causes
Pituitary
Adrenal – cancer, adenoma, hyperplasia
Ecotopic ACTH producing tumor
Hypercortisolism Work-up
24hr urine cortisol
Low-dose dexamethasone suppression test Suppression is normal Failure to suppress confirms Cushing’s syndrome
ACTH measurement Is it ACTH dependent or independent? Low ACTH – suggests adrenal cause High ACTH – pituitary or ectopic ACTH producing tumor
High-dose dexamethasone suppression test Suppression – suggests pituitary cause Failure to suppress suggests ectopic ACTH producing
tumor
CRH test Used if still can’t tell from above tests ACTH will increase with pituitary tumor, no change in
ACTH in ectopic ACTH producing tumor
A patient with a 1cm medullary carcinoma of the right thyroid and no clinically significant adenopathy is best treated with
A. Total thyroidectomy with central lymph node dissection
B. Right thyroid lobectomy and isthmusectomy
C. Total thyroidectomy
D. Right thyroid lobectomy and subtotal left thyroidectomy
A patient with a 1cm medullary carcinoma of the right thyroid and no clinically significant adenopathy is best treated with
A. Total thyroidectomy with central lymph node dissection
B. Right thyroid lobectomy and isthmusectomy
C. Total thyroidectomy
D. Right thyroid lobectomy and subtotal left thyroidectomy
MTC has high incidence of multicentricity, more aggressive course, & I-131 isn’t effective. For palpable lymph node in this case, do MRND.
What is the most common cause of congenital adrenal hyperplasia?
A. 17-hydroxylase deficiency
B. 21-hydroxylase deficiency
C. 11-hydroxylase deficiency
D. 18-hydroxylase deficiency
What is the most common cause of congenital adrenal hyperplasia?
A. 17-hydroxylase deficiency
B. 21-hydroxylase deficiency
C. 11-hydroxylase deficiency
D. 18-hydroxylase deficiency
21-hydroxylase
All of the following are direct effects of PTH except
A. Stimulates absorption of calcium by the small intestine
B. Stimulates resorption of calcium & phosphate from bone
C. Stimulates reabsorption of calcium by the kidney
D. Stimulates hydroxylation of 25-hydroxyvitamin D in the kidney
All of the following are direct effects of PTH except
A. Stimulates absorption of calcium by the small intestine
B. Stimulates resorption of calcium & phosphate from bone
C. Stimulates reabsorption of calcium by the kidney
D. Stimulates hydroxylation of 25-hydroxyvitamin D in the kidney
Effects of PTH
Stimulates calcium reabsorption in the kidney (distal convoluted tubule)
Activates osteoclasts bone resorption elevation of serum calcium
Inhibits reabsorption of phosphate by the kidney
Stimulates renal production of active vitamin D via 1-alpha-hydroxylase
Indirect stimulation of calcium reabsorption from gut via actions of vitamin D
The most important test in the work-up of a solitary thyroid nodule is
A. Sestamibi scan
B. FNA
C. Thyroid function tests
D. CT scan
E. Ultrasound
The most important test in the work-up of a solitary thyroid nodule is
A. Sestamibi scan
B. FNA
C. Thyroid function tests
D. CT scan
E. Ultrasound
A 60yo woman presents with a history of kidney stones and serum calcium is 11. The most likely diagnosis is
A. Parathyroid adenoma
B. Parathyroid hyperplasia
C. Parathyroid cancer
D. Breast cancer with bone metastasis
E. Secondary hyperparathyroidism
A 60yo woman presents with a history of kidney stones and serum calcium is 11. The most likely diagnosis is
A. Parathyroid adenoma
B. Parathyroid hyperplasia
C. Parathyroid cancer
D. Breast cancer with bone metastasis
E. Secondary hyperparathyroidism
A 60yo woman presents with a history of kidney stones and a palpable neck mass. Her serum calcium is 14.1. The most likely diagnosis is
A. Parathyroid adenoma
B. Parathyroid hyperplasia
C. Parathyroid cancer
D. Breast cancer with bone metastasis
E. Secondary hyperparathyroidism
A 60yo woman presents with a history of kidney stones and a palpable neck mass. Her serum calcium is 14.1. The most likely diagnosis is
A. Parathyroid adenoma
B. Parathyroid hyperplasia
C. Parathyroid cancer
D. Breast cancer with bone metastasis
E. Secondary hyperparathyroidism
Dissection of the superior thyroid arteries during total thyroidectomy is most likely to result in which of the following complications?
A. Aspiration
B. Voice fatigue
C. Hoarseness
D. Stridor
E. Loss of airway
Dissection of the superior thyroid arteries during total thyroidectomy is most likely to result in which of the following complications?
A. Aspiration
B. Voice fatigue
C. Hoarseness
D. Stridor
E. Loss of airway
After total thyroidectomy for follicular thyroid cancer, the best test to monitor for recurrent disease is
A. Serum calcitonin
B. Ultrasound of the neck
C. Serum thyroglobulin
D. Serum TSH
E. I-131 scan
After total thyroidectomy for follicular thyroid cancer, the best test to monitor for recurrent disease is
A. Serum calcitonin
B. Ultrasound of the neck
C. Serum thyroglobulin
D. Serum TSH
E. I-131 scan
A 73yo woman with perforated diverticulitis s/p Hartmann’s procedure with sepsis develops increasing pressor requirements & you suspect adrenal insufficiency. What initial test can help you make the diagnosis?
A. Cosyntropin stimulation test
B. Serum cortisol
C. 24hr urine cortisol
D. Basic metabolic panel
E. 24hr urine metanephrines
A 73yo woman with perforated diverticulitis s/p Hartmann’s procedure with sepsis develops increasing pressor requirements & you suspect adrenal insufficiency. What initial test can help you make the diagnosis?
A. Cosyntropin stimulation test
B. Serum cortisol
C. 24hr urine cortisol
D. Basic metabolic panel
E. 24hr urine metanephrines
BMP should reveal hyperkalemia, hyponatremia, hyperglycemia
Which of the following tests to evaluate for pheochromocytoma has the highest sensitivity?
A. Plasma catecholamines
B. Urine catecholamines
C. Urinary total metanephrines
D. Urinary VMA
E. Urinary free metanephrines & normetanephrines
F. 24hr urine cortisol
Which of the following tests to evaluate for pheochromocytoma has the highest sensitivity?
A. Plasma catecholamines
B. Urine catecholamines
C. Urinary total metanephrines
D. Urinary VMA
E. Urinary free metanephrines & normetanephrines
F. 24hr urine cortisol