9/30/2013

9/30/2013

Answers:

The most common cause of CHL in adults is ---, but the most common cause in children is---.
A) Cerumen Impaction; Otitis Media 
B) TM Perforation; Otitis Media 
C) Otitis Media; Cerumen Impaction 
D) Otitis Media; TM Perforation 
E)Cerumen Impaction; TM Perforation

In adults cerumen impaction is the most common cause, TM perf is the second most common cause.  In children Otitis media is the most common cause.

What is the greatest possible hearing loss, in terms of dB, a CHL can cause?

60 dB.  Hearing loss greater than 60 dB should be considered to have at least some SNL component.  Be suspicious of ossicular discontinuity for loss >50dB.

MC Questions:
What is cochlear otosclerosis?
A) When otosclerosis causes CHL 
B) When otosclerosis causes SNHL 
C) Stiffening of cochlear basal membrane
D) Stiffening of the stapes footplate 
E) None of the above

Free Response Question:
What amount of hearing loss is expected when the canal is impacted with cerumen?

Quick Facts:
Otosclerosis
-abnormalities of bone metabolism affecting labyrinthine bone of inner ear.
-leads to stiffening/fixation of stapes to oval window.
-decreased movement = CHL
-treat with Stapedectomy, 90-95% success rate.
-can cause SNHL aka cohclear otosclerosis

9/27/2013

9/27/2013

Answers:

A patient complains of hearing loss.  A Weber test causes lateralization to the left ear and a Rinne test shows greater air conduction than bone conduction in the right ear.  What is the patient's likely diagnosis?
A)R CHL 
B)L CHL 
C) R SNHL 
D) L SNHL

In SNHL Weber lateralizes to better ear and Rinne shows better conduction of air than bone.  In CHL weber lateralizes to affected ear and Rinne shows better bone than air conduction.

Which test can confirm CHL, Rinne or Weber?  Why?

Only the Rinne test can confirm CHL by demonstrating greater bone conduction over air conduction (AKA "flipping forks").  The Weber test can only detect a difference between two ears but cannot assess whether it is due to CHL or SNHL.

MC Questions:
The most common cause of CHL in adults is ---, but the most common cause in children is---.
A) Cerumen Impaction; Otitis Media 
B) TM Perforation; Otitis Media 
C) Otitis Media; Cerumen Impaction 
D) Otitis Media; TM Perforation 
E)Cerumen Impaction; TM Perforation

Free Response Question:
What is the greatest possible hearing loss, in terms of dB, a CHL can cause?

Quick Facts:
Otosclerosis
-ear usually appears normal 
-often a fhx 
-Rinne must be negative in order to have surgery 
-Most common treatment is stapedectomy, 90-95% success rate.

9/26/2013

9/26/2013

Answers:

A patient with hyperthyroidism who recently underwent a laparoscopic appendectomy complicated by wound infection and who is noncompliant with her home medications presents to the ED with fever, agitation and abdominal pain.  On exam the patient is diaphoretic, tachycardic and in afib.  Which of the following is part of appropriate initial management of this patient?
A) Propranolol 1-2 mg IV 
B) Propylthiouracil 250mg q6 
C) Saturated Iodine PO 
D) Aspirin 325 
E) All of the above 
F) None of the above

Appropriate management includes: 

-Propranolol 1-2mg IV, Methimazole 20mg/6h (propylthiouracil is associated hepatocellular injury)   

-Hydrocortisone (50g) given every 6 hrs while symptomatic.   

-Giving oral saturated iodide one hour after giving methimazole can slow hormone release but it should not be given initially.  Avoid aspirin as it displaces T3 from TBG and can worsen symptoms.

What antiarrhythmic drug may cause both hyperthyroidism and hypothyroidism?

Amiodarone Induced Hyperthyroidism

-amiodarone is 37.3% iodine (half life 50dys)

-more likely to cause hypothyroidism.  Only 2% on the drug get hyperthyroidism.

-symptoms blunted be antiadrenergic effect of drug.

-may occur years after starting the drug.

-Two etiologies:    

-excess iodine from drug w/ abnormal gland = increased hormone production    

-thyroiditis causes be the drug

-Ultrasound useful in differentiating the two: increased doppler flow in excess hormone production, decreased in thyroiditis.

-Treat with higher dose thioamides and B-blockers.

-Can also give prednisone

MC Questions:
A patient complains of hearing loss.  A Weber test causes lateralization to the left ear and a Rinne test shows greater air conduction than bone conduction in the right ear.  What is the patient's likely diagnosis?
A)R CHL 
B)L CHL 
C) R SNHL 
D) L SNHL

Free Response Question:
Which test can confirm CHL, Rinne or Weber?  Why?

Quick Facts:
-CHL in External Ear = Impacted Cerumen; Foreign Body; External Otitis 
-CHL in middle ear = TM perforation; Tympanosclerosis; Retracted TMs; Otitis Media; Cholesteatoma; Eustachian Tube dysfunction; Temporal Bone Fracture; Otosclerosis

9/25/2013

9/25/2013

Answers:

An elderly patient with "apathetic hyperthyroidism" might present with symptoms such as...
A) weight loss, severe depression and slow afib 
B) weight loss, heat intolerance, sweating 
C) anxiety, insomnia, palpitations 
D) hand tremor, increase stool freq,weight loss

Elderly patients with hyperthyroidism do not always have the classic presentation of tachycardia, insomnia, tremor, heat intolerance etc.  Depression, weight loss and Afib should raise suspicions of hyperthyroidism in elderly patients and TFTs should be performed.

What are the three symptoms that are unique to Graves' hyperthyroidism?

Ophthalmopathy (exophthalmos) 

Dermopathy (thick skin) 

Osteopathy (pretibial myxedema).

MC Questions:
A patient with hyperthyroidism who recently underwent a laparoscopic appendectomy complicated by wound infection and who is noncompliant with her home medications presents to the ED with fever, agitation and abdominal pain.  On exam the patient is diaphoretic, tachycardic and in afib.  Which of the following is part of appropriate initial management of this patient?
A) Propranolol 1-2 mg IV 
B) Propylthiouracil 250mg q6 
C) Saturated Iodine PO 
D) Aspirin 325 
E) All of the above 
F) None of the above

Free Response Question:
What antiarrhythmic drug may cause both hyperthyroidism and hypothyroidism?

Quick Facts:
Hydatidiform Mole
-Produce chorionic gonadotropin which has TSH-like activity.
-No clinical evidence of hyperthyroidism but lab workup can show suppressed TSH and elevated T3/4.
-Resect Mole.

9/24/2013

9/24/2013

Answers:

A patient with medullary carcinoma and multiple mucosal neuromas presents to the ED with palpitations, diaphoresis and an impending feeling of doom.  What is their likely diagnosis?
A) MEN1 
B) MEN2a 
C) MEN2b 
D) FMTC

-MEN1=pituitary, parathyroid and pancreatic tumors (3Ps),

-MEN2a = medullary CA, Pheo, Hyperparathyroidism

-MEN2b = medullary carcinoma, Pheo and multiple mucosal neuromas.

-FMTC = MEN2a with MTC as the only manifestation, must r/o pheo or primary hyperparathyroidism

What is the rule of 3rds with respect to medullary thyroid carcinoma?

Rule of 3rds: 1/3 sporadic, 1/3 MEN2, 1/3 familial w/o other associations.

MC Questions:
An elderly patient with "apathetic hyperthyroidism" might present with symptoms such as...
A) weight loss, severe depression and slow afib 
B) weight loss, heat intolerance, sweating 
C) anxiety, insomnia, palpitations 
D) hand tremor, increase stool freq,weight loss

Free Response Question:
What are the three symptoms that are unique to Graves' hyperthyroidism?

Quick Facts:
Thyroid Crisis:  acute exacerbation of thyrotoxicosis.
-in pts with poorly controlled hyperthyroidism who undergo surgery/radioactive iodine/parturition or stressful illness.
-Symptoms = fever, flushing, sweating, tachycardia, a fib, CHF, agitation, delirium, coma, abdominal pain, n/v/d, jaundice.
-Treat Quickly!      
-Propranolol 1-2mg IV, Methimazole 20mg/6h    
-Giving oral saturated iodide one hour after giving methimazole can slow hormone release.    
-Hydrocortisone (50g) given every 6 hrs while symptomatic    
-Avoid aspirin as it displaces T3 from TBG.

9/23/2013

9/23/2013

Answers:

If the following is found on histology of a thyroid nodule this would indicate a diagnoses of...

A) Papillary Carcinoma 

B) Papillary Adenoma 

C) Follicular Carcinoma 

D) Follicular Adenoma 

E) Medullary Carcinoma 

F) Anaplastic Thyroid Cancer

This is a psammoma body which is highly suggestive of papillary carcinoma.

What is the most common type of thyroid cancer?  What is the second most common type?

The most common type is papillary (75%).  The second most common type is follicular (16%).

MC Questions:
A patient with medullary carcinoma and multiple mucosal neuromas presents to the ED with palpitations, diaphoresis and an impending feeling of doom.  What is their likely diagnosis?
A) MEN1 
B) MEN2a 
C) MEN2b 
D) FMTC

Free Response Question:
What is the rule of 3rds with respect to medullary thyroid carcinoma?

Quick Facts:
Graves’
-autoimmune disorder.  Immunoglobulins bind and activate TSH receptor.
-F>M
Clinical Findings
-symptoms unique to Graves’: ophthalmopathy (exophthalmos) dermopathy (thick skin) and osteopathy (pretibial myxedema).
Lab Tests:
-decreased TSH and increased T4/3
-If no ophthalmopathy then dx w/ TSI (specific for graves’)

9/20/2013

9/20/2013

Answers:

All of the following are risk factors for papillary carcinoma except...

A)Radiation exposure
B)Hashimoto's
C) Cowden Syndrome
D) FAP
E) None of the above are risk factors

Prior radiation exposure, Cowden syndrome (multiple hamartomas) and Familial Adenomatous Polyposis are all risk factors for papillary carcinoma.

What are the four main types of thyroid cancer?

Papillary, Follicular, Medullary and Anaplastic

MC Questions:
If the following is found on histology of a thyroid nodule this would indicate a diagnoses of...

A) Papillary Carcinoma 

B) Papillary Adenoma 

C) Follicular Carcinoma 

D) Follicular Adenoma 

E) Medullary Carcinoma 

F) Anaplastic Thyroid Cancer

Free Response Question:
What is the most common type of thyroid cancer?  What is the second most common type?

Quick Facts:
Medullary Thyroid CA
-5% of thyroid CA
-From parafollicular/C cells
Clinical Findings
-Histo = sheets of cells w/ amyloid (stains congo red).
-Secretes calcitonin, histaminase, prostaglandins, serotonin.
-Extension often occurs to LN, muscle and trachea and can spread via heme to lunds/viscera.-Radiation not effective, treat surgically.
-MEN 2b has most aggressive form, MEN 2a and FMTC are least aggressive.
-Rule of 3rds: 1/3 sporadic, 1/3 MEN2, 1/3 familial w/o other associations.
-MEN2a = medullary CA, Pheo, Hyperparathyroidism
-MEN2b = medullary carcinoma, Pheo and multiple mucosal neuromas.
-FMTC = MEN2a with MTC as the only manifestation, must r/o pheo or primary hyperparathyroidism.
-Germline RET mutations present in MEN2 and FMTC.  Offer testing to family members.

9/19/2013

9/19/2013

Answers:

A 55 year old patient with a single 1.9cm thyroid nodule found to be papillary carcinoma on FNA with no evidence of LN involvement should receive what treatment?
A) Lobectomy and modified neck dissection with postop L-thyroxine, no surveillance needed 
B)Total thyroidectomy and modified neck dissection with postop Lthyroxine and long term surveillance  
C) Total thyroidectomy with postop Lthyroxine, no surveillance needed 
D) Total thyroidectomy with postop Lthyroxine and longterm surveillance 
E) Total thyroidectomy with postop ablation, Lthyroxine and long term surveillance

For patients with lesions >1cm, age>45 or multicentric/invasive lesions treatment involves total thyroidectomy.  If there is evidence of LN spread then modified neck dissection is warranted.  Postop, ablation should be performed, treatment with L-thyroxine should be started and long term surveillance should be carried out. If the patient is less than 45 with a <1cm lesion and no evidence of extrathyroidal spread then lobectomy or total thyroidectomy is warranted with postop L-thyroxine but no ablation or long term surveillance.

Why is it difficult to r/o follicular carcinoma on FNA?

The difference between follicular adenoma and follicular carcinoma is that follicular carcinoma demonstrates pericapsular/vascular invasion.  As it is possible to obtain an FNA from a follicular carcinoma that does not incorporate the capsule and thus cannot r/o invasion into it, it is difficult to tell these two pathologies apart.

MC Questions:
All of the following are risk factors for papillary carcinoma except...

A)Radiation exposure
B)Hashimoto's
C) Cowden Syndrome
D) FAP
E) None of the above are risk factors

Free Response Question:
What are the four main types of thyroid cancer?

Quick Facts:
Follicular Carcinoma
-2nd most common thyroid cancer (16%)
Clinical Findings
-Histo = small follicles w/ small, cuboidal cells and poor colloid formation.
-Carcinoma has capsule/vascular invasion whereas adenoma does not.  FNA hard to do this so get frozen section @ surgery.
-Can synthesize thyroglobulin and concentrates iodine (thus radioactive iodine treatment works)
-Slightly more aggressive than papillary CA.
-Hurthle cell and poorly differentiated subtypes don't take up radioiodine and have higher mets/recurrence.

9/18/2013

9/18/2013

Answers:

What percentage of FNAs demonstrate a benign lesion?
A) 10% 
B) 25% 
C) 50% 
D) 75% 
E) 90%

Roughly 75% are benign, 10% are considered suspicious, 5% are malignant, 15% are nondiagnostic

If a thyroid nodule is evaluated with a 99mTc pertechnetate scan and found to be "hot", what significance does this have?

"Hot" nodules have a low risk for malignancy, "cold" nodules are more likely to be malignant and an FNA should be performed.

MC Questions:
A 55 year old patient with a single 1.9cm thyroid nodule found to be papillary carcinoma on FNA with no evidence of LN involvement should receive what treatment?
A) Lobectomy and modified neck dissection with postop L-thyroxine, no surveillance needed 
B)Total thyroidectomy and modified neck dissection with postop Lthyroxine and long term surveillance  
C) total thyroidectomy with postop Lthyroxine, no surveillance needed 
D) total thyroidectomy with postop Lthyroxine and longterm surveillance 
E) total thyroidectomy with postop ablation, Lthyroxine and long term surveillance

Free Response Question:
Why is it difficult to r/o follicular carcinoma on FNA?

Quick Facts:
Papillary Carcinoma
-most common thyroid cancer (75%)
-best prognosis (5% mortality @ 20 yrs if no local invasion @ presentation)
-Risk factors = childhood irradiation, fhx, cowden syndrome (multiple hamartomas) and familial adenomatous polyposis coli.
Clinical Findings
-Histo = single layers of thyroid cells in avascular projections or papillae.  Large pale nuclei, intranuclear inclusion bodies and anaplastic features.
-"Psammoma bodies" = laminated calcified spheres = dx papillary carcinoma.
-Can be pure or mixed w/ follicular.
-Higher risk of recurrence in tall cell, columnar or diffuse sclerosing subtypes.
-Lesions grow slowly, rarely converts to anaplastic CA.

9/17/2013

9/16/2013

Answers:

Thyroid stimulating immunoglobulin (TSI) is positive in 90% of patients with...
A) Hashimotos
B) de Quervains
C) Graves'
D) Hypothyroidism
E) None of the above

Thyroid stimulating immunoglobulin (TSI) is + in 90% of Graves’ pts but negative in normals and hashimotos.

Describe the three maneuvers used when examining the thyroid gland.

The pt should slightly flex their neck (in order to relax the SCM), one should observe the thyroid while the pt swallows (often a sip of water), and one should palpate the thyroid from behind by placing the three middle fingers on the gland while the pt swallows.

MC Questions:
What percentage of FNAs demonstrate a benign lesion?
A) 10% 
B)25% 
C)50% 
D) 75% 
E) 90%

Free Response Question:
If a thyroid nodule is evaluated with a 99mTc pertechnetate scan and found to be "hot", what significance does this have?

Quick Facts:
Management of thyroid nodules
-Malignant = total thyroid w or w/o neck dissection.
-Follicular often indeterminate due to difficulty telling follicular carcinomas from follicular adenomas on FNA.    
-Need vascular/capsular invasion to diagnose follicular carcinoma.
-If benign, follow up clinically w/ serial US.-L
-Thyroxine not recommended.
-If increasing in size, reexamine w/ FNA.
-Eval is same in pregnancy but no radionucleotide scans are done.  If differentiated cancer found can delay surgery until post delivery.

9/16/2013

9/16/2013

Answers:

A patient with a high TSH, low T4 and normal T3 likely has ---? A patient with low TSH, low T4 and low T3 likely has---?
A) Subclinical hypothyroidism, Central hypothyroidism 
B) Primary Hypothyroidism; Central hypothyroidism 
C) Subclinical hypothyroidism; Primary hypothyroidism 
D) T3 toxicosis, drug induced hypothyroidism 
E) Hyperthyroidism; Sick Euthyroid

Primary hypothyroidism often presents with high TSH as the thyroid gland is not responsive in producing thyroid hormone. T3 may be low or normal in this situation as what T4 remains can continue to be converted to T3. Central hypothyroidism will have a low TSH due to pituitary failure which then results in low T3/4.

What is the rate of "incidentalomas" found on high resolution thyroid ultrasounds in the general population?

Estimates range from 19-67%.

MC Questions:
Thyroid stimulating immunoglobulin (TSI) is positive in 90% of patients with...
A) Hashimotos
B) de Quervains
C) Graves'
D) Hypothyroidism
E) None of the above

Free Response Question:
Describe the three maneuvers used when examining the thyroid gland.

Quick Facts:
Thyroid Nodules Clinical Findings
-nodules >1cm undergo further eval.
-1cm< eval if risk factors:     
-suspicious US findings, adults younger than 30 or over 60, hx of irradiation, fam hx-recent growth, hoarseness, dysphagia or obstruction.-US may distinguish cyst from solid nodule     
-suspicious findings = microcalcifications, irregular borders, increased blood flow.
-Once primary thyroid disease r/o w/ TFT do FNA.
-FNA indications:  solitary nodule, multiple nodules that exist in multinodular goiter.
-If more than two nodules >1cm, fna the one with odd US findings.
-If all are <1cm fna dominant one.
-If subclinical/overt hypothyroid w/ nodules:     
-99mTc pertechnetate or 123I prior to FNA.     
-"Hot" nodules low risk, "cold" nodules more malignant and do FNA.
-Use 23-25 gauge-FNAs: 75% benign, 10% suspicious, 5% malignant, 15% nondiagnostic.
-Serous fluid = cystic lesion = less likely malignant.
-FNA nondiagnostic if no follicular epithelium or too much blood.-95% accurate.

9/13/2013

9/13/2013

Answers:

The half life of T4 is --- whereas the halflife of T3 is ---.
A) 7hrs, 7dys 
B) 7dys,24hrs 
C) 24hrs, 12hrs 
D) 1 wk, 3 dys 
E) 12 hrs, 2 hrs

The half life of T3 is 24hrs, the half life of T4 is 7dys. This is why patients on L-thyroxine can be dosed daily and that skipping a few days of therapy if the patient cannot take PO is not life threatening.

Name two common drugs that limit T4-->T3 conversion.

Medications that inhibit T4-->T3 conversion include amiodarone, glucocorticoids, propylthiouracil, propranolol, and iodine.

MC Questions:

A patient with a high TSH, low T4 and normal T3 likely has ---? A patient with low TSH, low T4 and low T3 likely has---?
A) Subclinical hypothyroidism, Central hypothyroidism 
B) Primary Hypothyroidism; Central hypothyroidism 
C) Subclinical hypothyroidism; Primary hypothyroidism 
D) T3 toxicosis, drug induced hypothyroidism 
E) Hyperthyroidism; Sick Euthyroid

Free Response Question:
What is the rate of "incidentalomas" found on high resolution thyroid ultrasounds in the general population?

Quick Facts:
Thyroid Physical Exam
-3 maneuvers to examine thyroid    
-pt should slightly flex neck to relax SCM    
-observe thyroid while pt swallows    
-palpate from behind while pt swallows

9/12/2013

9/12/2013

Answers:

When the thyroid gland enlarges due to illness, it most often extends in what direction?
A) Superior and Anteriorly 
B) Inferior and Anteriorly
C) Superior and Posteriorly 
D) Inferior and Posteriorly 
E) Laterally

Superior extension is blocked by the sternothyroid muscle.

What is are the two major roles of thyroid peroxidase in the production of thyroid hormone?

TPO is a catalyst for both the oxidation of iodide and iodination of tyrosyl residues in thyroglobulin as well as the linking of pairs of iodotyrosine molecules within thyroglobulin to form T4 and T3.

MC Questions:

The half life of T4 is --- whereas the halflife of T3 is ---.
A) 7hrs, 7dys 
B) 7dys,24hrs 
C) 24hrs, 12hrs 
D) 1 wk, 3 dys 
E) 12 hrs, 2 hrs

Free Response Question:
Name two common drugs that limit T4-->T3 conversion.

Quick Facts:
Thyroid Nodules
-High res US show nodules in 19-67% of general population i.e. incidentalomas.
-5-15% of nodules are malignant.
Clinical Findings
-incidental nodules >1cm should be investigated.
-palpable has same malignancy as nonpalpable.
-investigate <1cm if:    
-suspicious US findings    
-adult younger than 30    
-older than 60    
-hx of head/neck irradiation    
-hx of thyroid cancer (cowden’s syndrome)         
-multiple hamartomas        
-increased risk of cancer