Thyroid & Adrenal Disorders - landscape

Instructions

This self-assessment study guide has 4 questions, each written using learning objectives from your Thyroid & Adrenal Disorders lecture. Not all learning objectives are covered. Participation/scores are not monitored. FYI this program makes noise sometimes.

Symbols

A clipboard will bring up relevant patient information.

A lightbulb in the top right corner of a page indicates that the page contains answers or explanations.

Q1

Classify each of the following as being associated with hypothyroidism or hyperthyroidism.

Question 2

Read the patient case on the following page then answer subsequent questions. You will have access to the patient information while answering the questions.

Q2

GT is a 46-year-old patient with complaints of joint and muscle pain, constipation, cold intolerance, and overall fatigue. He has no pertinent past medical history and is currently taking no medications.

• TSH: 7.1 mlU/L (H)
• Free T4: 0.6 ng/dL (L)
• Free T3: 1.8 pg/mL (L)
• Positive TPOAb

• Weight: 95 kg
• IBW: 71 kg

Q2

Q2

• Based on the patient’s symptoms and high TSH, he likely has hypothyroidism – this rules out Grave’s disease and overt hyperthyroidism.
• High TSH combined with low T3 and T4 he has overt hypothyroidism (T3 and T4 can be normal in subclinical hypothyroidism.)
• The presence of TPOAb points to Hashimoto’s thyroiditis. Hashimoto’s thyroiditis is also the most common cause of hypothyroidism in the US.

Q2

Q2

Patients with TSH between 4.5 - 10 mlU/L are treated when certain risk factors are present, such as ASCVD, heart failure, or positive TPOAb. GT has positive TPOAb, so it would be appropriate to start treatment with his TSH level. All patients should be treated with TSH >10.

Q2

Q2

Liothyronine → levothyroxine is preferred over liothyronine Methimazole → used for hyperthyroidism

Levothyroxine dosing

• Initial dosing methods (see slide 29)
• Full replacement dose (1.6 mcg/kg/day) → young/middle-aged adults or iatrogenic

• Start lower and titrate → older adults and subclinical hypothyroidism

⇨ GT can start at full replacement dose

• Ideal body weight (IBW) should be used to calculate dose – 1.6 mcg/kg/day.
• GT’s IBW = 71 kg
• 1.6 mcg/kg X 71 kg = 113.6 → closest dose is 112 mcg

Q2

Q2

If it is determined that dose should be adjusted, it would be appropriate to increase medication dose by 50 mcg daily. ⇨ It would be appropriate to adjust in 50 mcg if TSH ≥10 mlU/L. GT’s TSH was never that high.If it is determined that dose should be adjusted, it would be appropriate to increase medication dose by 12.5 mcg daily. ⇨ It would be appropriate to adjust in 12.5 - 25 mg increments.If dose is adjusted, GT should have TSH levels checked again in 4-8 weeks.⇨ Check every 4-8 weeks with initiation, dose adjustments, or changes in formulation.GT should be counseled to take levothyroxine in the morning with breakfast.⇨ If taken in the morning, levothyroxine should be taken 30-60 minutes before food and other medications.Adherence and timing of administration should be assessed before adjusting dose. ⇨ Before increasing the dose, it should be confirmed that patient is administering correctly and consistently.

Q3

Choose the drug that best matches each description below. Once you are finish selecting, press send to see how you did.

Question 4

There are six statements regarding adrenal disorders on the following page. Mark each as true or false.

Q4

Q4

• When Cushing Syndrome develops as a result of exogenous steroids, the steroids should be immediately stopped. FALSE
• If glucocorticoids can be safely discontinued, they should be tapered slowly (See last bullet for why.)

• Cushing Syndrome is more commonly caused by administration of exogenous glucocorticoids than by overproduction of endogenous glucocorticoids. TRUE

• In addition to glucocorticoids, progestins can be a cause of iatrogenic Cushing Syndrome. TRUE
• Examples in lecture were medroxyprogesterone acetate and megestrol acetate.

• One possible complication of Cushing Syndrome is osteoporosis. TRUE

• Aldosterone’s main role is regulation of fat, carbohydrate, and protein metabolism. FALSE
• Aldosterone’s main role is maintaining electrolyte and volume homeostasis. Glucocorticoids regulate fat, carbohydrates, and protein metabolism.

• Abruptly discontinuing exogenous glucocorticoids could lead to adrenal crisis. TRUE
• Administration of exogenous glucocorticoids suppresses the body’s HPA axis, so the adrenal glands reduce/stop cortisol production. Adrenal glands will not immediately resume normal cortisol production if the exogenous glucocorticoids are suddenly stopped, which leads to adrenal insufficiency (adrenal crisis). Slowly tapering glucocorticoids allows the HPA axis and adrenal glands to recover their normal function.

• Age: 46
• PMH: N/A
• Meds: N/A
• Current complaints
• Joint & muscle pain
• Constipation
• Cold intolerance
• Fatigue

• TSH: 7.1 mlU/L (H)
• Free T4: 0.6 ng/dL (L)
• Free T3: 1.8 pg/mL (L)
• Positive TPOAb
• Weight: 95 kg
• IBW: 71 kg

• Age: 46
• PMH: N/A
• Meds: N/A
• Current complaints
• Joint & muscle pain
• Constipation
• Cold intolerance
• Fatigue

• TSH: 7.1 mlU/L (H)
• Free T4: 0.6 ng/dL (L)
• Free T3: 1.8 pg/mL (L)
• Positive TPOAb
• Weight: 95 kg
• IBW: 71 kg

• Age: 46
• PMH: N/A
• Meds: N/A
• Current complaints
• Joint & muscle pain
• Constipation
• Cold intolerance
• Fatigue

• TSH: 7.1 mlU/L (H)
• Free T4: 0.6 ng/dL (L)
• Free T3: 1.8 pg/mL (L)
• Positive TPOAb
• Weight: 95 kg
• IBW: 71 kg

• Age: 46
• PMH: N/A
• Meds: N/A
• Current complaints
• Joint & muscle pain
• Constipation
• Cold intolerance
• Fatigue

• TSH: 7.1 mlU/L (H)
• Free T4: 0.6 ng/dL (L)
• Free T3: 1.8 pg/mL (L)
• Positive TPOAb
• Weight: 95 kg
• IBW: 71 kg