🤔 MEDIUM

Writing a question set on the thyroid gland gives me the perfect opportunity to tell one of my favourite medical-dad jokes:

Chap goes to the doctor and says “it hurts when I touch my neck, my arm or my chest”. The doctor says, “you’ve broken your finger”.

Good luck! 

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thyroid disorder part one

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Question 1

Stem 1 of 5

A 40 year-old female has been uncomfortable with heat intolerance for the last few months. She reports notable, unexpected weight loss and “fluttering of the chest” which is confirmed as a palpitations. Her history includes a 15 pack-year history of smoking. A tremor is noted on examination, as well as injected eyes bilaterally. There is a swelling in the anterior triangle of the neck bilaterally.

Given the vignette, which is the more likely diagnosis?
A
Amiodarone intoxication
B
DeQuervain’s thyroiditis
C
Graves’ disease
D
Pituitary adenoma
E
Sheehan syndrome
Question 1 Explanation: 
DeQuervain’s is a post-viral thyroiditis associated with a hyperthyroid picture and painful swelling. Sheehan syndrome is a thyroiditis associated with avascular necrosis of the pituitary gland secondary to postpartum haemorrhage. A pituitary adenoma would not present in this way, without visual or mammillary symptoms. Amiodarone intoxication can cause both hyperthyroid and hypothyroid signs, though there is no indication the patient has been taking this medication. Graves disease is an autoimmune condition causing hyperthyroidism that fits this patient’s presentation and demography.
Question 2

Stem 2 of 5

What is the most common orbitopathy associated with Graves’ disease?
A
Dysmetria
B
Exophthalmos
C
Eyelid retraction
D
Fixed miosis
E
Nystagmus
Question 2 Explanation: 
Pretibial myxoedema and ophthalmopathy are associated with Graves’ disease uniquely. This is a painless hyperthyroid picture, 90% of which present with eyelid retraction. Other signs are rarer.
Question 3

Stem 3 of 5

Which physiological mechanism best explains the most likely diagnosis?
A
Antibodies to thyroid receptors
B
Atheromatous disease
C
Infarct of the superior thyroid artery
D
Innate immunity dysregulation
E
Post-viral infection damage
Question 3 Explanation: 
The patient with Graves disease has an autoimmune comorbid picture with antibodies raised to the TSH-R of the thyroid gland. This causes an increase in the formation, and release, of T3 and T4 (thyroid hormones). This will increase the basal metabolic rate of the patient.
Question 4

Stem 4 of 5

Which of the below options best represent the more likely thyroid function test results in this patient?
A
TSH depressed, FT3 depressed, FT4 depressed
B
TSH depressed, FT3 elevated, FT4 elevated
C
TSH elevated, FT3 depressed, FT4 depressed
D
TSH elevated, FT3 depressed, FT4 elevated
E
TSH elevated, FT3 elevated, FT4 elevated
Question 4 Explanation: 
In primary hyperthyroidism, the thyroid stimulating hormone of thyrotropic anterior pituitary cells are downregulated. However, the gland is released from this regulation and negative feedback is failing. Therefore free T3 and free T4 circulating levels remain persistently high.
Question 5

Stem 5 of 5

Which would be the most useful investigation for differentiating Graves disease from toxic multinodular goitre?
A
Arteriogram
B
Cervical radiograph
C
FT3, FT4 test
D
Radioactive iodine
E
TSH test
Question 5 Explanation: 
Radioactive iodine is uptaken into the thyroid gland, as normal iodine/iodide is. Regions of greater activity, ie adenomas for instance, will “glow” on RAIU (radioactive iodine uptake) relative to the less-active areas. Graves disease may show diffuse activation of the gland, but TMNG (toxic multinodular goitre) will show clear pockets of activation only. This is the rationale behind the “nodular” appearance. It is both palpable, and visible on this radioactive imaging.
Question 6
Which of the below medications are likely to cause hypothyroidism? Select all which may apply.
A
Amiodarone
B
Carbimazole
C
Levothyroxine
D
Lithium
E
Propylthiouracil
Question 6 Explanation: 
All of these medications are known to cause hyperthyroidism. For your examinations, be sure to know amiodarone, carbimazole, PTU and lithium. It may not help you, but I use CALPOL to remember it! Carbimazole, Amiodarone, Lithium and PTU Often Lowers.
Question 7
Overt hypothyroidism, according to NICE CKS 2021, has which definitional picture?
A
TSH depressed, FT4 elevated
B
TSH elevated, FT4 depressed
C
TSH elevated, FT4 elevated
D
TSH normal, FT4 depressed
E
TSH normal, FT4 elevated
Question 7 Explanation: 
Hypothyroidism will have a decrease of thyroid glandular output (ie FT3, FT4) but an overcompensation of high TSH from the anterior pituitary trying to “turn on” the gland further.
Question 8
Which of the following is least likely to occur as a consequence of poorly managed hypothyroidism?
A
Coronary artery disease
B
Dyslipidaemia
C
Hyperovulation
D
Metabolic syndrome
E
Stroke
Question 8 Explanation: 
NICE CKS state clearly the risks of poorly managed hypothyroidism include: dyslipidaemia, metabolic syndrome, coronary artery disease, heart failure, infertility and subfertility.
Question 9
A post-thyroidectomy patient is placed on levothyroxine. Which is the most appropriate monitoring option in the near-term?
A
3 monthly TSH level
B
Annual TSH level
C
Monthly TSH level
D
Nil monitoring
E
Weekly TSH level
Question 9 Explanation: 
NICE CKS (2021) states that patients with overt hypothyroidism should be started on LT4 therapy, reviewing both the symptoms and TSH count every three months until stabilizing. Afterward, TSH need only be checked annually.
Question 10
The patient’s TSH has been stable for some time. How often should the patient be monitored?
A
3 monthly TSH level
B
Annual TSH level
C
Monthly TSH level
D
Nil monitoring
E
Weekly TSH level
Question 10 Explanation: 
NICE CKS (2021) states that patients with overt hypothyroidism should be started on LT4 therapy, reviewing both the symptoms and TSH count every three months until stabilising. Afterward, TSH need only be checked annually.
Question 11
Sheehan syndrome occurs as a consequence of post-partum haemorrhage. Avascular necrosis of which organ is responsible for the characteristic presentation?
A
Adrenal cortex
B
Anterior pituitary
C
Hippocampus
D
Hypothalamus
E
Posterior pituitary
Question 11 Explanation: 
In Sheehan syndrome, a postpartum haemorrhage starves the hypophyseal-hypothalamic portal system of sufficiently oxygenated and nutrient-rich blood. This leads to pituitary avascular necrosis and deranges thyroid hormone levels (amongst the other hormones).
Question 12
A patient presents three weeks after a self-resolving upper respiratory tract infection with new-onset constipation and feeling incredibly warm. They have had torrential night sweats and have palpitations, with a resting tremor on examination. On palpation, there is a small swelling in the anterior neck triangle that is notably tender to touch.

What is the best-matched diagnosis?
A
Anaplastic carcinoma
B
DeQuervain’s thyroiditis
C
Hashimoto’s thyroiditis
D
Sheehan’s syndrome
E
Small cell thyroiditis
Question 12 Explanation: 
DeQuervain’s is a post-viral thyroiditis associated with a hyperthyroid picture and painful swelling.
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