Thyroid Disorders Board Review Questions, Free Endocrinology CME Quiz
This week's Med-Challenger free CME quiz - Thyroid Disorders - the quick quiz covers the most common symptoms of hypothyroidism, distinguishing human chorionic gonadotropin–mediated hyperthyroidism from Graves disease, appropriate first-line treatment for subacute thyroiditis, and diagnosis of exogenous hyperthyroidism.
A free sample Thyroid Disorders question included below. The full Thyroid Disorders CME quiz is free online for a limited time. You can earn AMA CME credit - and now you can earn ANCC contact hours as well! Play now.
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Here's this week's sample CME board review question on thyroid disorders:
A 33-year-old woman presents with hyperemesis. She is 8 weeks pregnant. She has no medical history and takes only prenatal vitamins. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Her review of systems is negative for tremors, diarrhea, heat intolerance, weakness, or palpitations.
Her vital signs are as follows: temperature 37 °C, heart rate 110 beats/minute, blood pressure 110/68 mm Hg, respiratory rate 16 breaths/minute, and oxygen saturation 99% on room air.
An astute medical student has ordered a thyroid panel, which shows that her thyroid-stimulating hormone (TSH) is 0.2 mIU/mL (normal range, 0.4-4.0 mIU/L), and her total free thyroxine (T4) level is elevated.
This triggers a repeat examination which shows an absence of thyromegaly or goiter.
What is the next best step in the management of her condition?
The correct answer is:
Check her thyroperoxidase antibody level
Distinguish human chorionic gonadotropin–mediated hyperthyroidism from Graves disease.
Human chorionic gonadotropin–mediated hyperthyroidism is a transient, mild hyperthyroidism that occurs early in approximately 10% to 15% of pregnancies; patients have no thyromegaly or goiter and thyroperoxidase antibodies are normal. The condition usually resolves by 20 weeks gestation without treatment. The emergency physician’s job is to exclude the diagnosis of Grave’s disease.
Human chorionic gonadotropin (hCG)–mediated hyperthyroidism is a transient, mild hyperthyroidism that occurs early in approximately 10% to 15% of pregnancies and is not due to intrinsic thyroid disease. hCG, which peaks during the first trimester, has the ability to stimulate the TSH receptor, resulting in elevated T4 levels and suppressed TSH concentrations.
In general, the symptoms consist of nausea and sometimes vomiting (and perhaps anxiety), resolving spontaneously by 20 weeks of gestation. The most severe form of hCG-mediated hyperthyroidism is hyperemesis, also known as transient hyperthyroidism of hyperemesis gravidarum.
Distinguishing this hCG-mediated hyperthyroidism (usually no treatment required) from Graves hyperthyroidism (treatment required) may be challenging; a key difference is that a patient with hCG-mediated hyperthyroidism will not have thyroperoxidase antibodies, whereas the person with Graves disease will have antibodies.
In addition, the person with Graves disease is more likely to have a goiter, and ultrasonography of the thyroid will show increased vascularity.
None of these (antibodies, goiter, increased vascularity) are present in the patient with hCG-mediated hyperthyroidism.
Nausea/vomiting are more pronounced with hCG-mediated hyperthyroidism than with Graves disease.
In some patients, serum TSH may remain suppressed or below normal after normalization of serum T4.
Ross DS. Overview of thyroid disease in pregnancy. Revised Apr 19 2021.
Cooper DS, Laurberg P. Hyperthyroidism in pregnancy. Lancet Diabet Endocrinol. 2013;1(3):238-249.
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