27 June Thyroid Disorders Face To Face Handout P1

ＭCQ BRIDGING COURSE:
EDOCRINOLOGY
Problem solving
Dr OVP
27 June 2019,
Melbourne, Australia
MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #1

THYROID
DISORDERS

Simplified scheme of the synthesis,
secretion, and actions of thyroid
hormones.
TRH, thyrotropin-releasing hormone;
TSH, thyroid-stimulating hormone;
T4, thyroxine;
T3, triiodothyronine;
D, deiodinase;
TR, thyroid hormone receptor.
Reference:
Camilla Pramfalk, Matteo Pedrelli, Paolo Parini,
Role of thyroid receptor β in lipid metabolism. -
Biochimica et Biophysica Acta (BBA) - Molecular Basis of
Disease, Volume 1812, Issue 8, August 2011, pp 929–937.
Courtesy: http://ars.els-cdn.com/content/image/1-s2.0-
S0925443910002978-gr2.jpg

THYROID FUNCTION TESTS :
Fundamentals of Hormonal Regulations
The hypothalamus secrets thyrotropin releasing hormone

(TRH), which stimulates production of thyroid stimulating
hormone (TSH), from the anterior pituitary.
TSH increases production and release of thyroxine (T4)

and triiodothyronine (T3) from the thyroid, which exert
negative feedback on TSH production.

THYROID FUNCTION TESTS (Cont’d) :
The thyroid produces mainly T4, which is 5-fold less
active than T3. 85% of T3 is formed from peripheral
conversion of T4. Most T3 and T4 in plasma is protein
bound to thyroxine-binding globulin (TBG).
The unbound portion is the active part. T3 and T4 increase

cell metabolism, and are thus vital for growth and mental
development. They also increase catecholamine effects.

TSH T4 Primary Hypothyroidism
TSH T4 Subclinical hypothyroidism
TSH T4 TSH secreting tumour or thyroid

hormone resistance
TSH T4 or T3 Hyperthyroidism
TSH T4 and T3 Subclinical hyperthyroidism
TSH T4 and T3 Pituitary disease (secondary

hypothyroidism)
TSH T4 and T3 Sick euthyroid (systemic
disease)
Causes of Primary Hypothyroidism
• Hashimoto thyroiditis (The most common cause in
Australia);associated with RA and DM type 1,
• Radioiodine therapy;
• Thyroidectomy;
• Transient (Subacute Thyroiditis, Silent Thyroiditis, Postpartum
Thyroiditis);
• Iodine deficiency or Iodine induced;
• Drug induced (Carbimazole, PTU, Iodine, Amiodorone,
Lithium)
• Infiltrative (Scleroderma, Amyloid Disease, Haemochromatosis,
TB)
• Associated with Turner syndrome, Down syndrome

Primary Hypothyroidism
• Symptoms:
Lethargy, constipation, cold intolerance, weight gain, depression,
hoarse voice, menorrhagia, later oligo- or amenorrhoea, cramps,
carpal tunnel syndrome, dementia by 65 years.
• Signs:
Bradicardia, dry skin and hair, brittle nails, puffy face, non-pitting
oedema (eyelids, hands, feet), may be goitre (multinodular),
delayed deep tendon reflexes, myopathy (proximal, painful).

• Diagnosis:
• TSH (normal level 0.4 – 4.0), if abnormal repeat TSH and check
the level of free T4 within 2 – 8 weeks.
• TPO a/b (seen in 10-15% of general population). Do annual
TFT if TPO a/b positive.
• Consider FNA if unclear.
• US if palpable thyroid nodules.
Cholesterol and triglyceride may be increased, occasionally

normochromic macrocytic anaemia, hyponatremia, increased
CK level.

• Treatment:
- Thyroxin dose 1.6 mcg/kg lean body mass.
- The aim to achieve TSH of 0.5 to 2 mU/L.
- In healthy elderly patients the initial dose 50 mcg per day.
- In patients with symptomatic angina 25 mcg per day.
- The aim to achieve TSH up to 5 mU/L.
- Stable concentration of thyroxin is 6 - 8 weeks.
- Follow-up: in 3 months, in 6 months, every year.
- Drug interaction: PPI, calcium carbonate, ferrous sulfate,
multivitamins, phosphate binders, coffee, OCP, anticonvalsants.
- Side effects: tachycardia, ectopic beats, osteoporosis.

• Planning surgery:
- When a patient who is euthyroid on L-Thyroxin requires
elective surgery, thyroxine can be safely withheld for up to a
week due to its long half-life.
- If a patient has inadequately treated or untreated
hypothyroidism, elective surgery should be deferred for several
weeks to allow time for the administered thyroid hormone to
work:
- risk of prolonged bleeding;
- anaesthesia cares risk of prolonged respiratory depression due to
reduction of anaesthetic clearance;
- prolonged wound healing.

Neonatal Hypothyroidism
The clinical features:
• Include coarse features
• Dry skin
• Supra-orbital oedema
• Jaundice
• Harsh cry
• Tongue protrusion
• Umbilical hernia
It is detected by routine neonatal heel prick blood testing.
Thyroxine replacement should be started as soon as possible, at least
before 2 weeks of age to avert intellectual retardation.

Q WOF is least likely in primary
hypothyroidism?
1. 65 year-old female with large multinodular goitre

2. 45 year-old female with depression
3. 28 year –old female with menorrhagia
4. 35 year-old woman with anaemia unresponsive to
iron, B12 and folic acid
5. 10 year-old boy with growth retardation and
diarrhea
Q A 60-year-old woman is complaining of a
swelling in her neck. From the history she has
rheumatoid arthritis and Sjogren syndrome.
Physical examination reveals a mildly nodular,
firm, rubbery goiter. T4 is 10 (N) and TSH 1,2 (N).
Thyroid peroxidase a/b is high.
WOF is the most likely diagnosis?
1. Graves disease
2. Hashimoto thyroiditis
3. Subclinical hypothyroidism
4. Subacute thyroiditis

Q Autoimmune thyroiditis can be confirmed by:
1. Thyroid peroxidase antibody (TPO)

2. Antinuclear antibody
3. Thyroid uptake
4. Thyroid aspiration
5. Antithyroglobulin antibody

Q Which of the following is the most frequent
cause of an elevated level of thyroid
stimulating hormone with a rubbery nodular
thyroid?
1. Follicular carcinoma
2. Follicular adenoma
3. Papillary carcinoma
4. Anaplastic carcinoma
5. Hashimoto thyroiditis

Q A patient hypotonic, poor development infant,
slanting eyes with epicanthic folds, flat occiput,
open fontanelle, single transverse palmar
crease.
What is the next investigation?
1. CT
2. US
3. TFT
4. Blood glucose

Q A 30 year – old woman is found to have a low
serum thyroxine level after being evaluated for
fatigue. Five years ago she was treated for
Graves’ disease with radioactive iodine.
The diagnostic test of choice is:
1. Serum TSH
2. Serum T4
3. TRH stimulation test
4. Radioactive iodine uptake

Q An elderly woman complains of feeling tired
for a couple of month. Physical examination,
including vital signs are normal. Laboratory
study shows normal free T4 level, but high TSH
was noted.
What is the best next step in the management?
1. Start thyroxin treatment

2. Repeat thyroid function test in 1 month
3. Check thyroid a/b
4. Start Methymazole
5. Reassure
Q A patient started on Thyroxin for treatment of
hypothyroidism.
When should you check his thyroid function

test?
1. 2 weeks
2. 4 weeks
3. 6 weeks
4. 3 months
5. 6 months

Q An old woman was found to be hypothyroid at
her home. Thyroxin was given with dose
adjusted to 75 mcg. In review after 3 months
investigations as following: T4 – reduced, TSH –
increased.
What to do?
1. Confirm adherence to current medications

2. Review later with the same medications
3. Increase thyroxine
4. Change the medication
Q An 55-year-old woman was recently diagnosed
with primary hypothyroidism. She started
Thyroxin 75 mcg. In review after 2 months
investigations as following: T4, T3 – normal, TSH
– increased.
What is the management?
1. Review later with the same dose

2. Increase Thyroxine
3. Recheck TFT

Q An old lady complains of lethargy and body
weakness after partial thyroidectomy.
What to give?
1. Levothyroxine 25 mcg

Q A 60 y.o. man develops lightheadedness and
palpitations. He has hx of thyroid disease and well-
controlled heart failure. He is on thyroxine, ACEI,
diuretic. ECG is given – clearly showed AFib.
What is the next step?
1. Cease thyroxine
2. Start digoxine
3. Start b-blocker
4. Start verapamil

Rate control of Atrial Fibrillation with rapid ventricular response

Q A 40-year old man with history of weight loss,
diarrhoea, reduced libido, malaise. He has
GORD and is taking omeprazole. TFT: free T4 7.2
(10-25), TSH 0.4 (0.4 - 4.0).
What should be done next?

1. TPO a/b
2. Start L-thyroxine
3. Investigate pituitary function
4. US for thyroid
5. Investigate his GIT for malabsorption

Q Patient on lithium.
What should you monitor for follow-up?
1. LFT
2. CBC
3. TFT
4. ECG

Q Same picture was given in exam from Google
and asked this boy born normally in a term
pregnancy and previous no complications in
mother.
What should be checked in mother?
1. LFT
2. Electrolytes
3. TFT
4. CBC

Courtesy: SAWA Radiology 2010, p.24&16 http://www.sawa2006.com/5Link/Radiology.html

Subacute Thyroiditis (de Quervain’s)
• Symptoms:
• Pain in the thyroid area, often radiating to the ears or jaw.
• Associated with:
- fever
- malaise
- symptoms of hyperthyroidism (early) or hypothyroidism (late).
• Investigations:
• ESR
• Absence of uptake on nuclear thyroid scan with technetium
pertechnetate (Tc-99m).

Subacute Thyroiditis (de Quervain’s)
• Treatment:
• If pain and constitutional symptoms are mild: beta blockers.
• For initial treatment of painful thyroiditis:

Simple analgesia with NSAID: aspirin, indomethacin, ibuprofen.
• In severe or persistent cases: prednisolone (orally).
• Thyroxin if the hypothyroid phase is prolonged or symptomatic.

Q A 29 –years – old woman present to your clinic
complaining of difficulty swallowing, sore throat, and
tender swelling in her neck. She has intermittent fever
over the past week. Several weeks ago she experienced
symptoms of URTI. On physical examination, she is
noted to have a small goitre that is painful to the touch.
Her oropharynx is clear.
Laboratory studies: white blood cell count of 14.000,
ESR of 53, TSH of 21. Thyroid a/b is negative.
What is the most likely diagnosis?
1. Autoimmune hypothyroidism
2. Cat-scratch fever
3. Graves’ disease
Q A 25-year-old woman complains of 2 weeks of
dysphagia and soreness in her neck, especially
when swallowing. She has earache and her two
children have had colds. She is anxious and
tremulous and her heart rate is 95/min. Her thyroid
gland is enlarged and tender. Thyroid hormone
levels are as follows: T4 225 nmol/L (83-160); T3 3,6
nmol/L (1,5-2,6); TSH < 0,1 mU/L (0,4-4,0).
Which of the following is/are likely to be correct?
1. She does not have Graves disease
2. Antithyroid antibody titres will be high
3. A thyroid scan will show low iodine uptake
4. She has been taking thyroxine surreptitiously
5. Radioiodine would be the treatment of choice
Q What is true about De Quevain’s goitre:
1. Total thyroxin and free T4 are decreased

2. RAIU will be increased
3. Steroids produce dramatic improvement
4. Antibiotics are useful
5. ESR may be elevated

Sub-acute Thyroiditis Graves’ Disease
Courtesy: SAWA Radiology 2010, p.24&16 http://www.sawa2006.com/5Link/Radiology.html

Q A 35-year-old woman presents with fever and
painful neck. Thyroid scan showed low uptake
of radioiodine. On exam she was found to have
tachycardia and tremor.
What is your management?
1. Ibuprofen and propranolol

2. Iodine
3. Thyroxine
4. Corticosteroids

Hyperthyroidism
• Causes:
• Graves disease
• Multinodular toxic goitre
• Autonomous functioning single nodule
• Thyroiditis: Hashimoto, Subacute, Drugs (Amiodarone )
• Resistance to thyroid hormones

Graves’ Disease
• Symptoms:
Weight loss despite increased appetite, heat intolerance, sweating,
diarrhoea, palpitation, oligomenorrhoea, anxiety, insomnia.
• Signs:
Sinus tachycardia; atrial fibrillation; fine tremor; warm, moist skin;
Ophthalmopathy (exophthalmos due to eyelid lag or retraction;
proptosis; periorbital oedema); pretibial myxoedema; proximal
myopathy (especially low limbs); bruit over the thyroid.
• Diagnosis:
TSH decreased, T4 & T3 are increased, TSH receptor antibody and
anti TPO, Tc-radionuclide thyroid scan.

Courtesy: Geneva Foundation for
Medical Education and Research
Courtesy: Dr. Meakin Mittu
Homoeopathic Clinics
http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1103765-138.jpg
http://drmeakinmittu999.wordpress.com/ailments/hyperthyroidism/

Graves’ Disease
• Antithyroid drugs
- Carbimazole: first line; 2nd and 3rd trimester of pregnancy.
- Propylthiouracil: first trimester of pregnancy, thyroid storm.
- B-blockers: symptomatic treatment.
• Surgery
- Thyroidectomy: compressive symptoms of large goitre,
ophthalmopathy, suspected malignancy, coexisting
hyperparathyroidism; planned pregnancy (< 6 months), lactation.
• Radioactive iodine: if planning pregnancy soon (delay

pregnancy for 6 months, avoid breastfeeding), contraindications
to surgery, side effects of drugs.

Q Which of the following may be a symptom of
hyperthyroidism?
1. Bradycardia
2. Course tremor of hands
3. Distal limb weakness
4. Proximal limb weakness
5. Narrow pulse pressure
Q Patient with unilateral proptosis.
What is the most likely cause?
1. Thyrotoxicosis
2. Maxillar sinus tumor
3. Zygomatic tumor
4. Optic neuritis

58yr od male pt, since six month watery
diarrhoea no mucus or blood ,with 3 kg
weight loss. Presented with a hx of
increasing difficulty to stand from sitting
and walk upstairs.
What is the cause?
a) Thyrotoxicosis
b) IBD
c) coeliac disease
d) campylobacter jujeni
e) bowel cancer

Q What is the best method to determine the
cause of thyrotoxicosis?
1. US of thyroid
2. CT of thyroid
3. Radioisotope scan
4. X ray of thyroid

Courtesy: SAWA Radiology 2010, p.25 http://www.sawa2006.com/5Link/Radiology.html

Normal Thyroid Scan, Displayed in Standard Projections
RAO = right anterior oblique;

LAO = left anterior oblique
Courtesy: http://www.racgp.org.au/afp/2012/august/goitre/

Scan Appearances of Common Causes of Thyrotoxicosis
A) Graves disease;
B) Multinodular goitre;
C) Thyroiditis;
D) Autonomous nodule

Q A Lady presents with tremor, palpitation,
intolerance to heat and oligomenorrhoea.
TSH is low.
What is the best investigation to do to get the

diagnosis ?
1. Radioactive iodine uptake

2. T4 and T3
3. No viral infection in the past

Q Patient comes to you with the results of
thyroid function tests:
TSH decreased, T3 and T4 are normal.
Which drug should not be given to this patient?
1. Iodine containing medicine

2. Beta blockers
3. Digoxin

Q What is the treatment of choice for the patient
with Graves disease?
1. Carbimazole
2. Radioactive surgery
3. Thyroid surgery
4. Oral corticosteroids

Q A young lady on Carbimazole for
hyperthyroidism. She decided to be pregnant and
her T4 and TSH is within normal range.
What is the next?
1. Continue carbimazole
2. Stop carbimazole
3. Stop carbimazole and commence propranolol
4. PTU was not an option

Q A 23-year-old lady accountant presented with weight
loss, nervousness, irritability, frequent palpitation and
excessive sweating of 2 month duration. She describes
her appetite as excellent. She is planning to come off her
OCP to have a baby. OE she has a mild diffusely enlarged
gland, pulse rate was 110, sweaty moist palms and
peripheral tremor. Her thyroid function test shows a
supressed TSH and raised T4, T3 levels.
What is the best management plan you can offer to
her?
1. Commence propranolol and carbimazole
2. Offer anti-thyroid medications and reassure that the drug is
safe in pregnancy
3. Recommend surgery
4. Offer radioiodine treatment and defer pregnancy for 6
months
Q A 16-weeks pregnant woman with thyrotoxicosis
on carbimazole.
What would you do?
1. Stop carbi and add prednisolone

2. Continue carbimazole
3. Replace with propanolol
4. Replace with PTU
5. Stop carbimazole
Q A patient WHO IS ON CARBIMAZOL FOR THE
LAST THREE WEEKS CAME TO SEE you
because he felt week and has a low grade fever
with sore throat on labs everything was normal
except low polymorphonuclears AND PLT: 150K.
What is the reason of that?
1. AML
2. CLL
3. APLASTIC ANEMIA
4. CARBIMAZOL AGRANULOCYTOSIS
Q A 30-year-old female with Graves’ disease
has been started on propylthiouracil.
She complains of low-grade fever, chills, and
sore throat, mouth ulcers.
The most important initial step in evaluating this
patient’s fever is
1. Serum TSH
2. Serum T3
3. CBC
4. Chest x-ray
5. Blood cultures
Q A 38-year-old woman, who had a subtotal
thyroidectomy 8 years previously, is
again thyrotoxic.
Which one of the following is the most
appropriate management?
1. Perform total thyroidectomy after preparation with
carbimazole.
2. Radioactive iodine after preparation with oral iodine
treatment.
3. Prescribe immunosuppressive treatment with azathioprine.
4. Control with cardimazole and then administration of
radioactive iodine.
5. Short-term treatment with beta blockers until remission occurs

Q A lady admitted for pneumonia is found to
have AF. TSH is decreased, T4 marginally
raised.
What will you do next?
1. Radio isotope imaging

2. Recheck TFT one month later
3. Carbimazole
4. ECHO

Postsurgical Complications: Haematoma
• Symptoms:
• Stridor, neck swelling, the neck wound is tense.
• Treatment:
• Emergency: bedside decompression.
• Cut the sutures and open the wound.
• Return to the operating room: evacuation the haematoma,
irrigation, careful haematosis.

Thyroid Storm
• Symptoms:
• Fever, tachycardia, vomiting, dehydration, acute abdomen,
confusion, delirium, coma.
• Complications: liver failure, stroke.
• Treatment:
• Propylthiouracil (orally or rectal)
• Lugol solution orally
• Dexamethazone orally or IV
• Propranolol orally

Hypocalcaemia
• Symptoms:
• If mild: Perioral tingling and numbness.

• Pin and needles in fingers and toes.
• If severe: Muscle spasm, Tetany.
• Treatment:
• If mild: Calcitriol plus Calcium Carbonate (oral)

• If severe: Calcium Chloride/Gluconate (I/V)

Hoarseness of Voice
• Symptoms:
• Injury of recurrent laryngeal nerve results in true vocal-fold
paresis or paralysis.
• Unilateral: hoarseness, dysphagia and aspiration.
• Bilateral: biphasic stridor, respiratory distress.
• Investigations:
• Indirect and fiberoptic laryngoscopy.
• Treatment:
• Unilateral – may reverse during 6 months, if not surgery
reinnervation.
• Bilateral – emergency tracheotomy.

Q The patient 24 hours after thyroidectomy
develops stridor. On examination BP and Pulse
are normal.
What is the most likely cause?
1. Bleeding into the wound

2. Thyroid storm
3. Wound infection
4. Septicaemia
5. Pulmonary atelectasis
Q A patient 3 hours after an operation on the
thyroid gland has developed stridor.
What is your management:
1. Intubation
2. Remove skin sutures
3. Tracheostomy
4. Remove skin and deep sutures
5. Call surgeon

Q A thyrotoxic patient was subjected to
subtotal thyroidectomy after she had been made
euthyroid by medical treatment. The day after
the operation her temperature is 39 C, pulse
110/min, regular.
WOF is the most likely cause?
1. Pulmonary atelectasis
2. Thyroid storm
3. Pulmonary embolus
4. Wound infection
5. Septicaemia
Q A 28-year-old lady comes to the physician to
explore the cause of an endocrine disorder.
Physical examination reveals a solitary thyroid
nodule. Laboratory studies showed an increased
serum calcitonin level. A biopsy confirmed the
presence of a carcinoma. The patient is scheduled
for a total thyroidectomy.
All of the following are potential complications of
this treatment, except?
1. Stridor
2. Hoarseness of voice
3. Thyroid storm
4. Numbness and tingling in the lips and fingers
5. Hypothyroidism

Q A 45-year-old undergoes thyroid surgery to
remove a nodular goiter. Afterward, the surgen
returns daily to lightly tap to the external auditory
meatus to see weather this causes the patient’s
facial muscle to twitch.
This physical sign is matter of WOF electrolyte

distirbances?
1. Hyperchloremia
2. Hyperkalemia
3. Hypernatremia
4. Hypocalcemia
5. Hyperphosphatemia

Q A patient 3 days after thyroidectomy
developed finger and perioral numbness.
Ca level is low.
What to give?
1. Ca Carbonate
2. Calcium Carbonate and vit. D3
3. Calcitriol
4. Calcitriol and Calcium Carbonate

MIDLINE NODE SWELLING
• Thyroid nodule (moves upon swallowing).
• Thyroglossal cysts (moves upwards on tongue

protrusion).
• Dermoid cyst (beneath chin).

General Characteristics of
Thyroid Nodule
• Prevalence:
3-7% revealed by physical examination;
25% detected by ultrasound
More common in women
Increased in prevalence with age
• May be single or multiple
• Functional or nonfunctional
• Most patients are euthyroid and asymptomatic

General Characteristics of
Thyroid Nodule
• May present with compression symptoms:
- cough
- dysphagia
- hoarseness
- stridor
- shortness of breath
• If haemorrhage into a nodule: tenderness and
sudden increase in size.

Thyroid Nodule
Courtesy: Northern Endocrine

http://www.northernendocrine.com.au/images/thyroid_nodule.jpg?524

What is the main goal of
evaluation?
• The main goal is to identify the small subgroup

of individuals with malignant lesions

Diagnostic Approach to a Patient with a Thyroid Nodule

Which Thyroid Nodules to Biopsy
• High risk history* >5 mm
• Abnormal cervical lymph All nodules†
node
• Microcalcification >1 cm
• Solid nodule >1 cm
• Mixed cystic – solid >1.5–2 cm
• Spongiform >2 cm
• Purely cystic FNA not indicated
* High risk history includes head and neck irradiation, thyroid cancer in a first degree relative,
radiotherapy or radiation exposure as a child, uptake on F–18 fluorodeoxyglucose positron
emission tomography, multiple endocrine neoplasia type 2, elevated calcitonin
† In the case of cervical lymphadenopathy the cervical node itself is usually biopsied and, if
thyroid cancer is present, a total thyroidectomy performed with the entire specimen subjected
to histological examination

Courtesy: Thyroid Clinic http://www.thyroid.com.au/thyroid-information/thyroid-imaging/

Fine Needle Aspiration
Cytological report
• Benign
• Malignant
• Atypical
• Follicular neoplasm
• Insufficient

CT Scan Indications
• Confirmed malignancy
• Retrosternal goitre
• Compression symptoms
• Distant metastasis

Q A middle aged woman presents with a
midline swelling in the neck which moves
upwards on swallowing.
What is the likely diagnosis?
1. Thyroglossal cyst
2. Thyroid nodule
3. Branchial cyst

Q A young woman is found to have a thyroid
nodule. There is no pain, hoarseness or local
symptoms. Serum TSH is N. T3, T4 are N.
The next step in evaluation is:
1. US
2. Thyroid function test
3. Thyroid scan
4. Surgical resection
5. Fine needle aspiration of thyroid

Q A 40-year old woman presents with a neck
mass that has been growing slowly over the
next 2-3 years and now around 2 cm in diameter,
irregular, relatively hard, moves with
swallowing. She has no palpable cervical lymph
nodes. TFT is normal.
What is the best step?
1. Reassurance this is a thyroid cyst
2. Thyroid US
3. FNA of the nodule
4. CT scan of the neck and chest
5. Thyroid uptake scan
Q A 40-year-old woman presented to you with
diffuse neck enlargement. O/E there are
multiple nodules on right and left lobules of the
thyroid. You were able to identify the isthmus.
No signs/symptoms of thyrotoxicosis.
What will be your next step in management?
1. FNA
2. US of the neck
3. CT scan of neck
4. TSH
5. Thyroid nuclear scan

Q Patient had thyroid nodule, FNA under US
control done and nodule gets smaller after
aspiration.
On histopathology few red cells, macrophages
and very few follicular cells are seen.
Report says: follicular lesion of undetermined
significant.
What will you advise to the patient?
1. Thyroid lobectomy
2. Radiation
3. Repeat FNA in 1 year
4. Reassure

Q The middle age woman presents with a large
swelling at the centre of the neck.
On examination there is no exophthalmos.
TSH, T4, T3 are normal.
1. Ca thyroid
3. Thyroid cyst
4. Multinodular goitre
5. Graves’ disease

Q A palpable and apparently solitary nodule in
the thyroid is most likely:
1. A solitary cyst
2. Part of multinodular goitre
3. An adenoma of thyroid
4. Localised Hashimoto disease

Q The accompanying illustration of the thyroid
scan in a patient in her 20s.
The patient most likely presented with which
one of the following symptoms?
1. Pathological fracture
2. Lump in the neck
3. Weight loss
4. Pain in the neck
5. Dry coarse skin

Technetium Isotope Scan
Technetium Isotope Scan of

the Thyroid in a Patient in
her 20s.
Courtesy: "Handbook of Multiple Choice Questions", Australian Medical Council, 2009. -

805pp., p.210.

Q A 70-year-old man complains of progressive
dysphagia and dyspnea. He claims his face
becomes flushed and congested when he rises his
arms.
WOF investigations is most likely to lead to his

diagnosis?
1. Thyroid US
2. CXR
3. Doppler of internal carotid
4. CT scan of neck
Courtesy: Clarissa Wallace, and Kerry Siminoski, The Pemberton Sign. Ann Intern
Med. 1 October 1996;125(7):568-569.
http://annals.org/data/Journals/AIM/19867/6FF1.jpeg

Retrosternal Goitre
• C/F: persistent cough at night, dyspnoea,
stridor, choking symptoms, dysphagia.
• Retrosternal dullness
• Retrosternal goitre/Tracheal or mediastinal
invasion is suspected:
- Next step – an X-ray
- Best step – CT scan of the neck/upper chest
Treatment: total thyroidectomy.
Courtesy: http://intranet.tdmu.edu.ua

CT scan of the chest showing the relationship of the goiter with the trachea and the
mediastinum.
Courtesy: Thoracic medicine http://www.thyroid.com.au/thyroid-information/thyroid-
imaging/

Malignancy is more likely IF the patient
• Had irradiation of head and neck in the past

• Has a history of Hodgkin’s disease
• Male
• Elderly
• Has an associated limphadenopathy
• Child
• Has single thyroid lump
• Has horseness of voice reflecting laryngeal
nerve involvement

There are 5 Types of Neoplasia
• Pappilary (70%). Often in young. Spread: nodes
and lung. Treatment: if <1 cm – partial
thyroidectomy. If >1 cm - total thyroidectomy with
cervical node dissection followed by radio
ablation. Give T4 to suppress TSH.
• Follicular (<25%) Middle age. Spreads early via
blood (bone, lungs). Treatment: total
thyroidectomy, followed by radio ablation + TSH
suppression.
• Follow-up: thyroglobulin, if increased – whole
body radioiodine scanning/PET scan.
There are 5 Types of Neoplasia
• Medullary (5%) may be a part of MEN 2
syndrome. It originates from the parafollicular ‘C’
cells which secrete calcitonin. Family history may
be positive.
• Treatment: total thyroidectomy + node clearance +
radio ablation.
• Lymphoma (5%) Large, rapidly growing thyroid
mass, painless in elderly. May present with stridor
or disphagia. Radiotherapy, chemotherapy.
• Anaplastic (rare) Elderly, poor response to any
treatment. Survival at 3 years is less than 10%.
Anaplastic Carcinoma
• Rapidly enlarging (within a few weeks) stone hard
neck mass causing local compressive symptoms
such as:
- dysphagia
- dysphonia
- stridor
- dyspnoea and neck pain or tenderness
• Cervical regional nodal involvement (40%)
• Vocal cord paralysis
• Distant metastasis to lungs or bones
Anaplastic Carcinoma
• Investigations:
• US, FNA/Core biopsy/Chest X-ray/chest CT
• Management:
• Total thyroidectomy (in earlier stage)
• External-beam radiation (in advanced stage)
• Chemotherapy

Q An 82-year-old man was referred for a
evaluation of a rapidly increasing mass in the
left thyroid. The tumor evolved over 3 weeks
and caused palsy of the left recurrent nerve and
dysphagia.
1. Papillary cancer
2. Multinodular goitre
3. Oesophageal cancer
4. Anaplastic carcinoma

Q WOF suggests thyroid malignancy:
1. Stridor
2. Retrosternal extension
3. Recurrent laryngeal nerve involvement
4. Mass 3 cm across
5. Painful mass

Q A patient has a single lump on one side of
thyroid.
All following situations suggest malignant

except:
1. Single nodule
2. Ultrasound showed a solid nodule
3. Thyroid scan showed a ’hot’ nodule
4. Associated with serum thyroglobulin increased
5. Associated with hoarseness of voice

COLD and HOT Nodules
Courtesy: SAWA Radiology 2010, p.29 http://www.sawa2006.com/5Link/Radiology.html

Q In which type of thyroid malignancy family
history is important ?
1. Papillary
2. Follicular
3. Medullary
4. Anaplastic
5. Lymphoma

Q An old lady comes with a lump in the left side
of the neck for 3 months which is 3 cm size
papillary carcinoma with no metastatic spread.
What is the most appropriate management?
1. Total thyroidectomy
2. Left thyroid lobectomy
3. Radio I 131 ablation
4. Radio I 131 ablation followed by thyroidectomy
5. Suppression with thyroxin

Q A 30-year-old man is evaluated for a thyroid
nodule. The patient reports that his father died
from thyroid cancer and that a brother had a
history of recurrent renal stones.
Blood calcitonin is 2000 (N level is 100),
serum Ca and P levels are N.
Before referring the patient to a surgeon, you
should:
1. Obtain a liver scan
2. Perform a calcium infusion test
3. Measure urinary catecholamines
4. Administer suppressive doses of thyroxine and
measure levels of TSH
5. Treat the patient with radioactive iodine
• The MEN syndrome are a group of genetic
syndromes inherited in an autosomal dominant
manner, where there are functioning hormone-
producing tumours in multiple organs.
• MEN type 1 Parathyroid hyperplasia/adenoma,
Pancreatic endocrine tumours (usually
gastrinoma or insulinoma), pituitary adenoma –
usually prolactinoma or GR secreting tumour
• MEN type 2 Medullary thyroid carcinoma,
Pheochromocytoma, Parathyroid hyperplasia
(but less than 20% have increased level of Ca)

• For this patient described, the markedly
increased calcitonin levels indicate the diagnosis
of medullary carcinoma of the thyroid. In view
of the family history, the patient most likely has
MEN type 2. It’s worthwhile to notice that
pheochromocytoma may exist without
hypertension. Pheochromocytoma must be rule
out before the surgery by measuring urinary
catecholamine levels. The presence of such a
tumour might expose the patient to a
hypertensive crisis during surgery.

Q A patient with a tender neck swelling moves
with swallowing, hoarseness and difficulty in
breathing at night. O/E: smooth swelling in the
anterior triangle of neck, dullness of
percussion at upper sternal border.
1. Multinodular diffuse goitre

2. Papillary carcinoma
3. Anaplastic cancer
4. Haemorrhage in nodule of multinodular goitre

2.. A 36 years old man presents with a
thyroid swelling since one month. The
swelling is dull on percussion and has a
smooth border. He is complaining of
hoarseness of voice and difficulty
breathing on lying down as the swelling is
heavy and compresses the trachea.
What is your diagnosis?
A. Retrosternal multinodular goitre
B. Pappillary carcinoma
C. Medullary carcinoma
D. Thyroid cyst

A 47-year-old patient with a painless neck swelling,
moves with swallowing, hoarseness and difficulty in
breathing at night, gradually increasing for 2 months.
On examination there is a swelling about 5 cm in the
anterior triangle of neck. Dullness on the percussion at
upper sternal border.
1. Multi-nodular goitre with retrosternal extension
2. Anaplastic carcinoma of thyroid
3. Haemorrhage in the nodule of MNG
4. Papillary carcinoma of thyroid
5. Follicular carcinoma of thyroid

MAIN
REFERENCES:

• John Murtagh.
General Practice. McGraw Hill, 6th edition,
2015. – 1508pp.
• Endocrinology Expert Group.
Therapeutic Guidelines. Version 5.
Therapeutic Guidelines Limited, Melbourne.
2014. – 420pp.
• Australian Medical Council.
Handbook of Multiple Choice Questions.
2009. – 805pp.

• Henry M.Kronenberg, Sholmo Melmed, Kenneth
S.Polonsky, P.Reed Larsen.
Textbook of Endocrinology. 11th edition.
Saunders Elsevier. 2008. – 1911pp.
• Murray Longmore, Ian Wilkinson, Tom Turmzei,
Chee Kay Cheung.
Oxford Handbook of Clinical Medicine.
7th edition. Oxford University Press. 2007. –
841pp.
• Australian Family Physician.
Goitre. Causes, investigation and management.
August - 2012

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ＭCQ BRIDGING COURSE:

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #1

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #2

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #3

Fundamentals of Hormonal Regulations

The hypothalamus secrets thyrotropin releasing hormone

TSH increases production and release of thyroxine (T4)

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #4

The unbound portion is the active part. T3 and T4 increase

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #5

TSH T4 TSH secreting tumour or thyroid

TSH T4 and T3 Subclinical hyperthyroidism

TSH T4 and T3 Pituitary disease (secondary

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #7

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #8

Cholesterol and triglyceride may be increased, occasionally

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #9

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #10

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #11

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #12

1. 65 year-old female with large multinodular goitre

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #15

1. Thyroid peroxidase antibody (TPO)

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #16

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #17

What is the next investigation?

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #18

The diagnostic test of choice is:

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #19

What is the best next step in the management?

1. Start thyroxin treatment

When should you check his thyroid function

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #21

1. Confirm adherence to current medications

What is the management?

1. Review later with the same dose

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #23

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #24

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #25

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #26

What should be done next?

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #27

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #28

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #29

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #30

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #31

• If pain and constitutional symptoms are mild: beta blockers.

• For initial treatment of painful thyroiditis:

• In severe or persistent cases: prednisolone (orally).

• Thyroxin if the hypothyroid phase is prolonged or symptomatic.

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #32

What is the most likely diagnosis?

1. Total thyroxin and free T4 are decreased

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #35

Courtesy: SAWA Radiology 2010, p.24&16 http://www.sawa2006.com/5Link/Radiology.html

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #36

What is your management?

1. Ibuprofen and propranolol

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #37

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #38

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #39

MCQ Bridging Course 2019 ENDOCRINOLOGY Dr O.Pronyakova Slide #40

• Radioactive iodine: if planning pregnancy soon (delay