ENDOCRINOLOGY BOARDS ABIM EXAM /ALL VERSIONS &
SUBJECTS INCLUDED, 2024-2025.
Hyperthyroidism basics - CORRECT ANSWERS -Causes: autoimmune Graves dz
(most common), toxic MNG, toxic adenomas
Symptoms: anxiety, irritability, insomnia, restlessness, wt. loss, diarrhea, heat
intolerance, alopecia, onycholysis, , dyspnea, abnormal menses, gynecomastia,
decreased libido, ED
Exam - warm skin, thyroid "stare", HTN, tachycardia, A.fib or ectopy (20%, more
common in elderly)
Look for in new a-fib, depression, FTT in the elderly
Graves disease - findings - CORRECT ANSWERS -Caused by thyroid stimulating Abs
Exam- diffuse, soft goiter, exopthalmos (increased risk in smokers), pretibial edema,
immune-mediated heme abnromalities (ITP, pernicious anemia)
Dx - exam, TSH low, FT3/FT4 high
Can see elevated alk phos, hypercalcemia, anemia, thrombocytopenia
RAIU - increased homogenous uptake
Graves disease treatment - CORRECT ANSWERS -Antithyroid drug (PTU,
methimazole-MMI), ablation (radioactive I, surgery)
Use MMI if not pregnant - less side effects; PTU in pregnancy
drug side effects - hepatic toxicity, agranulocytosis-unpredictable, don't check for unless
sx)
Can use B-blockers for adrenergic sxs
Surgery if pregnant, cold nodule, relapse after radiation
Thyroid Storm - CORRECT ANSWERS -High mortality rate, precipitated by surgery,
infection, iodine load (amiodarone, contrast dye)
Sx - hyperthyroid, HTN, CHF, tachycardia, N/V/D
Dx - undetectable TSH, high FT4
Severe metabolic stress->stress causes adrenal insuff, can't completely replace despite
high cortisol levels - CV collapse
Treatment for thyroid storm - CORRECT ANSWERS -Interrupt physiologic response
with Propranolol or esmolol
Block new hormone synthesis- high dose PTU or MMI
Block release of preformed hormone- stable iodine
Block peripheral conversion- iodinated contrast agents, propranolol, steroids, PTU (not
MMI)
Broad spectrum antibiotics until infection excluded
Supportive care in ICU
Types of thyroiditis - CORRECT ANSWERS -Acute - usually bacterial (rare)
Subacute - viral
,Chronic - autoimmune (Hashimoto's), painless, postpartum thyroiditis
Subacute thyroiditis - CORRECT ANSWERS -30-50 y/o, F>M
Viral infection, causes granulomas in the thyroid gland, become fibrotic, then returns to
normal in a few months
Very tender neck +/- fever, pain radiating to ear
Can hypo/hyper/or euthyroid
Labs - Initially- elevated T3/T4, decreased TSH, progresses to hypothyroid; elevated
ESR
RAIU decreased
Self-limited, no tx unless severe (ASA, NSAIDs, steroids if refractory or systemic sxs)
Chronic autoimmune thyroiditis (Hashimoto's) - CORRECT ANSWERS -Most common
thyroid problem (4%), most common cause of hypothyroidism
Risks - genetic, other autoimmune dz
Gradually become hypothyroid, can have hyperthyroid initially
Painless, smooth, firm, irregular goiter
95% have anti-TPO abs
RAIU decreased
Sx, thyroid labs depend on the stage in dz
Painless thyroiditis - CORRECT ANSWERS -Can be either hypo or hyperthyroid
Hyperthyroid first 2-4 wks, then hypothyroid 4-12 wks, then recover
Exam- diffuse painless goiter
50% go on to have anti-TPO abs and Hashimoto's
Postpartum thyroiditis - CORRECT ANSWERS -10-15% of postpartum women
Hyper or hypothyroid sxs
ESR nl, many have anti-TPO abs
Radiation thyroiditis - CORRECT ANSWERS -Usually occurs 7-10 d after exposure
Euthyroid sick syndrome - CORRECT ANSWERS -Body does not need much T3, so
converts T4 to rT3-> low T3, low/nl TSH, T4; think of this is ill pt with these labs, not
pituitary insufficiency
If need to confirm, check rT3 - high in ESS, low in pituitary insuff.
Thyroid nodule basics - CORRECT ANSWERS -5-10% malignant, 95% cold, 85% of
those benign; hot nodules are almost always benign
5% of people with prior neck irradiation get nodules
Hot nodules are never malignant; don't biopsy!
Evaluate all cold nodules, even in Graves, MNG
Don't screen for nodules unless risk factors, but w/u all palpable nodules
Risk factors for thyroid nodules - CORRECT ANSWERS -Hx head/neck radiation
FH thyroid cancer
, Age<20, >70
Male
Growing nodule, firm or hard
Lymphadenopathy
Fixed nodule
Compression sxs- dysphonia, dysphagia, cough
What are primary, secondary, and tertiary disease? - CORRECT ANSWERS -Primary -
problem with the gland that secretes the hormone (ie: thyroid doesn't produce thyroid
hormone)
Secondary - problem is the gland that controls the primary gland (ie. pituitary doesn't
produce TSH to stimulate the thyroid)
Tertiary - problem with the gland that controls the secondary gland that controls the
primary gland (ie. hypothalamus not producing TRH ->no TSH from pituitary -> no
T3/T4 from thyroid)
How does the hypothalamus control the pituitary? - CORRECT ANSWERS -Controls
the anterior pituitary via hormones
Controls the posterior pituitary via neurohypophysis - direct nerve stimulation
Posterior pituitary functions - CORRECT ANSWERS -Secrete ADH and oxytocin
ADH regulation - CORRECT ANSWERS -Anterior pituitary - osmoreceptors to control
ADH release and thirst
Increased release rapidly with elevated osmolarity
Also see increased release with nausea
ADH osmolar release set point is affected by:
Lower set point (release at lower osm) with pregnancy and pre-menses
Higher set point with chronic hypovolemia, acute HTN, corticosteroids
Anterior pituitary - hormones and controls (6 hormones) - CORRECT ANSWERS -1.
ACTH - peak 3-4 am, nadir 10-11pm; stimulates corticosteroids and androgens from
adrenals; increase with corticotropin releasing hormone, physical/psych stress
2. Growth hormone - GHRH increases, somatastatin decreases, both from
hypothalamus
3. LH & FSH - produced by gonadotrophs; increased by pulsatile secretion of GnRH
from hypothalamus; Inhibin from ovary & testes decreases FSH (only) production
4. PRL - tonic inhibition from hypothalamic dopamine; increase with sleep, stress,
lactation, nipple stimulation; Metaclopramine, phenothiazines (decrease dopamine)
increase PRL; Hypothyroid modestly increases PRL
5. TSH - stim by TRH from hypothalamus, inhibited by T3, T4, somatastatin
Pituitary adenoma cell types - CORRECT ANSWERS -1. Lactotrophs - secrete PRL;
tied, most common macroademona
2. Gonadotrophs -tied, most common macroademona; presents as mass effect +/- silent
or panhypopit or gonadotropin hypersecretion
