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- Measure TSH
o If high or normal, then high risk
Get U/S; Usually f/u with FNA (esp if >1cm)
o If low, then low risk
Get RAIU scan
Cold/nonfunctioning/decreased uptake: U/S & FNA
Hot/functioning/increased uptake: tx hyperthyroid sxs
o Malignant: surgery
o Benign: repeat U/S
o Inconclusive: repeat FNA

Thyroid Cancer

- FNA if cancer risks, suspicious US findings, normal/high TSH, cold nodule on iodine 123
scintigraphy with low TSH
- Papillary cancer: most common; psammoma bodies (large cells with ground glass cytoplasm;
inclusion bodies/central grooving; grainy lamellated calcifications)
- Follicular thyroid cancer: thyroid epithelial; large number of follicular cells; invasion of
tumor capsules
- Medullary thyroid cancer: MEN2; C cells/parafollicular cells; calcitonin high; hypoCa
- Anaplastic: elderly; bad!


- Normal or increased RAIU: graves (diffuse uptake), diffuse nodular goiter (diffuse), toxic
nodule (focal), toxic multinodular goiter (methimazole, PTU)
o Methimazole: agranulocytosis, teratogen, cholestasis
o PTU: hepatic failure (maybe agranulocytosis)
If pt complains of fever and sore throat, stop PTU/methimazole and check
o Radioiodine ablation: perm hypothyroidism, radiation, worsening opthalmopathy
(give steroids + ptu/methimazole)
o Surgery: perm hypo, recurrent laryngeal damage, hypoparathyroidism
- Decreased RAIU: painless thyroiditis (TPO antibodies- beta blocker for sxs), subacute de
quervain painful thyroiditis (steroids), factitious (low thyroglobulin), struma ovarii (high
thyroglobulin; sestamabi scan ovaries)
o Subacute de Quervain thyroiditis: postviral, hyperthyroid, painful goiter, high
ESR/CRP, low radioiodine uptake (just releasing preformed hormone)
Tx: beta blockers and NSAIDs or steroids for pain
- Hyperthyroidism: bone loss risk
o Anxiety, palpitations, tachycardia, heat intolerance, weight loss, goiter, HTN,
tremors, hyperreflexia, proximal muscle weakness, lid lag, a fib
- Cold nodule: thyroid cancer risk
- Thyroid storm: due to surgery, trauma, infection, iodine contrast, child birth
o Tachy, HTN, high fever, tremor, AMS, lid lag
o Propranolol FIRST! Then PTU or methimazole (+/- iodine, steroids)

Hashimoto (chronic lymphocytic thyroiditis)

- Hurthle cells (eosinophilic cytoplasm)

- Hypothyroidism can cause hyperlipidemia, hyponatremia, high AST/ALT, high CK
- Can cause recurrent miscarriages
- Antithyroid peroxidase (anti-TPO) and anti thyroglobulin
- Can progress to lymphoma: enlarged, firm goiter with dysphagia, hoarseness, fever,
nightsweats, weight loss, facial plethora, distended veins all due to compression of cancer
- Estrogen therapy: increase thyroid binding globulin; increase total T4;in euthyroid pt,
thyroid gland will make more thyroid so free T4 will be normal
o But in hypothyroid patients, they need increase in their thyroxine meds
- Myxedema coma: hypothermia, hypotension, coma; IVF/warm blankets/ HIGH DOSE T4

Thyroid Others

- Euthyroid sick syndrome: pts with acute illness

o Low T3 (total or free); normal T4 and TSH
- Exogenous hormone: decreased diffuse RAIU scan; low thyroglobulin levels; small thyroid

- Usually first day; improves with diet/ambulation

- Distention without pain
- Upright and flat KUB: diffuse enlargement of both small and large bowel


- Usually later in the week; colicky pain that causes distension

- Borborygmi early: high pitched, fast bowel sounds; then progresses to no BS and no gas/stool
- Upright and flat KUB: dilated loops of bowel and air fluid levels and then decompressed bowel
(wide goes to narrow)
- Most common cause if prev surg: adhesions; if not then, hernias
- CBO or peritoneal: Exlap; incomplete ob: serial KUB and IVF/NPO/NGT

ACUTE ABDOMEN: guarding, rebound EX LAP!

Diverticulitis: LLQ pain; lots of bleeding; painless; low fever, leukocytosis; can perforate and cause
peritonitis so KUB if doubt; get CT scan; no colonoscopy until inflammation has decreased; NPO/IVF/Ab
(Cipro/metro, amp/gent/metro); if abscess then has to be drained; if refractory and recurrent then

IBD: chronic diarrhea +/- bloody

UC: bloody diarrhea; continuous lesion from rectum; crypt abscess; associated with PRIMARY
SCLEROSING CHOLANGITIS (p-ANCA; common in M); surgical removal is curative; colonoscopy at 8 yrs
and annual repeat; start with 5-ASA and then azathioprine/6MP and then TNF (infliximab, cyclosporine);
for acute flares: steroids
Crohns: watery diarrhea; mouth to anus; fistulas; terminal ileum: B12 def; transmural inflammation
with noncaseating granuloma; colo 8 yrs and repeat 1 yr; Abs, azathioprine, 6 MP start and then anti-
TNF; steroids and Abs for flare up; surgery only for fistulas and abscess drainage