Exam (elaborations) NR511 FINAL EXAM STUDY GUIDE

Exam (elaborations) NR511 FINAL EXAM STUDY GUIDE o Common M/S disorders o Common spine disorders o Metabolic disorders o Endocrine disorders o Wounds, lacerations & bites o Common hematological disorders o Common male GU disorders o Testicular disorders Chapters + lectures: Wk 5: o Chapter 52: Common Musculoskeletal Complaints o Chapter 53: Spinal Disorders o Chapter 54: Soft-Tissue Disorders o Lectures o Hollier o DE Wk6: o Chapter 57: Glandular Disorders (p. 880-897 only) o Chapter 59: Metabolic Disorders o Chapter 73: Common Injuries (p. only) table 73.1 o Review thyroid lecture again o Lectures o Hollier o DE Wk7: NR 511 FINAL EXAM STUDY GUIDE 1 NR511 Final Exam Study Guide o Chapter 46: Nocturia in Men (p. 682) & Testicular Pain (p. 685) o Chapter 49: Prostate Disorders o Chapter 50: Penile & Testicular Disorders o Chapter 61: Hematological Disorders o Lectures o Hollier o DE Completion of study guide: IIII 1. Signs and symptoms and management of musculoskeletal sprains/strains/dislocations Signs and symptoms and management of musculoskeletal sprains/strains/dislocations Sprains: stretching or tearing of ligaments that occurs when a joint is forced beyond its normal anatomical range First degree- stretching of ligamentous fibers Second degree- partial tear of part of the ligament with pain and swelling Third degree- complete ligamentous separation Sprain- sudden injury or fall that caused acute pain and swelling that got worse over a few hours, redness and bruising, active and passive ROM decreased. Radiography to rule out fx. Strain: muscle injury caused by excessive tensile stress placed on a muscle that results in stiffness and decreased function -effects muscle or tendon that connects a muscle to a bone, complain of “pulled muscle,” severe cases cause inflammation, swelling, weakness and loss of function-surgery may be needed Management: PRICE (protect, rest, ice, compression, elevation), limitation of activity, physical 2 NR511 Final Exam Study Guide therapy, NSAIDS, referral to ortho Dislocation- complete separation of 2 bones that form a joint Very painful and cause immobility, need immediate medical attention Referral to orthopedics for possible surgery or reduction with application of cast or splint. four cardinal signs of inflammation (erythema, warmth, pain, or swelling) -SPEW 2. Signs and symptoms and management of spinal disorders (spondylosis, stenosis, etc.) Cervical Spondylosis- neck stiffness, mild aching discomfort with activity. Pain and limited ROM occur with lateral rotation and lateral flexion of the neck toward the affected side. Weakness shoulder abduction- C5. Bicep weakness- C6. Tricep weakness-C7.Myelopathy- leg weakness, gait disturbance, balance problems, difficulty performing fine motor tasks, loss of bowel and bladder. Treatment- cervical traction, PT, pain relievers. Surgery for Myelopathy. Low back pain-Tenderness and decreased range of motion. Positive straight leg test. TreatmentNSAIDS, muscle relaxants, opioids, surgical, self-care, spinal manipulation Stenosis-pseudoclaudication causing radicular pain in the calves, buttocks, and upper thighs of one or both legs. Symptoms progress from a proximal to distal direction. Walking or prolonged standing causes pain and weakness in buttocks and legs. Stooping over helps relieve pain. Positive Romberg. Reflexes diminished. With bowel or bladder symptoms, sphincter tone may be decreased Management- surgical decompression. NSAIDS, folic acid, vitamin b12. PT-flexing the spine.Bicycling. Intermittent use of NSAIDs may be helpful, as well as folic acid or vitamin B12 supplementation in some cases depending on results of laboratory tests. Management revolves around physical therapy or an exercise program that focuses on flexing the spine. Flexion of the spine increases intraspinal volume. Bicycling is one exercise that is done with the spine in flexion. Improving abdominal muscle tone lifts the pelvis anteriorly and flexes the lumbar spine. Reduction of intra-abdominal fat is critical to achieving the objective. 3 NR511 Final Exam Study Guide Thus, weight loss may be pivotal. Lumbar flexion exercises increase spinal canal volume. Examples include exercise on all fours, arching the back, or in the fetal position. Exercises that extend the spine should be avoided (swayback). 3. Recognition and immediate management of cauda equina syndrome Immediate management of cauda equina syndrome. (P. 829) Cauda equina syndrome is a medical EMERGENCY and requires immediate decompression. If Cauda equina is confirmed, surgical lumbar decompression is necessary to halt neurological deterioration unless surgery is contraindicated for other medical reasons. *Rational on Davis Edge question: Low back pain accompanied by acute onset of urinary retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, loss of sensation in the buttocks and perineum, and motor weakness in the lower extremities is a red flag for cauda equina syndrome or severe neurologic compromise. Perianal numbness. Cauda equina compression is characterized by bilateral lower extremity weakness, anesthesia, or paresthesia of the perineum and buttocks (saddle anesthesia). There may or may not be bowel or bladder incontinence or bladder retention. When there is neurologic deficit affecting the bowel or bladder, these changes may not be reversed with surgical decompression, 4. Maneuvers and expected findings with joint pain (knee, shoulder, wrist, etc.) Neck pain-Spurling’s. Shoulder pain-Apley scratch test(reaching the scapula). Internal and external flexion. Internal and external abduction. Pain with abduction= early supraspinatus tendinitis and subacromial bursitis=early rotator cuff injuries. Wrist and hand-allen’s test= radial and ulnar arteries. Phalens test=median nerve compression. Tinel’s sign assess for compression neuropathy – tapping over nerve. Finkelsteins test- de Quervains disease. Thumb between finger and point. Knee Pain= Mcmurray, apprehension sign, bulge sign, inspect/palpate to assess effusion. Lachman, drawer sign – ACL, Thumb test - PCL MCL, LCL test are valgus and varus Tennis elbow cup coffee cup sign CTS-NSAIDs not effective 4 NR511 Final Exam Study Guide Achillies rupture – Thompson test 5. Initial assessment of FOOSH injury in correlation to anatomical location of radial head bone Lisa Callahan FOOSH - Falling On an Out Stretched Hand. After falling on an outstretched hand patients present after trauma with pain and swelling in the distal forearm or wrist. Numbness may be present if the medial nerve is affected. The mechanism of injury will often provide important clues to the diagnosis. The examination begins with gentle palpation to locate the area of point tenderness and includes a thorough neurovascular assessment. A radiograph of the wrist (including an oblique view) may be necessary to rule out fracture. Common fractures are the Colles fracture of the distal radius and the navicular (scaphoid) fracture of the anatomical snuffbox. It is not unusual to have a navicular fracture missed on radiography, so an orthopedic referral should be provided when the presenting complaint is pain and trauma to the soft-tissue area of the anatomical snuffbox. Scaphoid injury. 6. Assessment and management of Myofascial pain Trigger points within a muscle. Common cause of nonarticular rheumatic pain. Injections at the trigger point with saline, an anesthetic, or corticosteroid, dry needling, muscle relaxant tizanidine, NSAIDS, or cyclooxygenases-2 inhibitors. Tricyclic antidepressants. 7. Health promotion activities to prevent sport related musculoskeletal injuries Protection may refer to preventing the injury from occurring or making it less severe by wearing protective gear, such as helmets, wrist pads, and kneepads. Maintain adequate hydration and proper diet while playing sports. Stretch before the activity. Stop when you are injured, do not “tough it out”. 8. Osteopenia Osteopenia: • Osteopenia Is the precursor to osteoporosis. Osteopenia is categorized by the level of Tscores in relation to the results of a dual-energy x-ray absorptiometry scan or (DXA Scan), which measures the mineral content of bone. A T-score ranging from -1 to -2.5 would be classified as osteopenia. Pathophysiology: • It occurs secondary to uncoupling of osteoclast-osteoblast activity, resulting in a quantitative decrease in bone mass. Peak bone mass is typically achieved by males and females just prior to, or early-on in the 3rd decade of life. • Beyond age 30, bone resorption gradually becomes favored as dynamic bone remodeling continues into later decades of life. • Histologic specimens demonstrate markedly thinned trabeculae, decreased osteon size, and enlarged haversian and marrow spaces. 5 NR511 Final Exam Study Guide Osteopenia Prevention: • Certain habits can accelerate the process such as: o Smoking – prevents calcium uptake o Not getting enough calcium and vitamin D o Drinking too much ETOH o Use of certain medications (i.e.: corticosteroids and anticonvulsants) o Not getting enough weight-bearing exercise (at least 30 mins on most days). If your feet touch the ground during an exercise, it’s probably weight bearing. Running and walking are weight bearing. Swimming and biking are not – non-weight bearing o Falls • Women are more likely to have low bone density than men, but it’s no longer viewed as solely a women’s condition. • Approx. a third of white and Asian men over age 50 are affected. • Percentages for Hispanics (23%) and blacks (19%) are lower, but still sizable. Current National Osteoporosis Foundation (NOF) recommends testing for: • Women 65 and older • Postmenopausal women younger than 65 who have one or more risk factors, which include being thin • Postmenopausal women who have had a fracture • For men: testing is done more on a case-by-case basis. Osteopenia Treatment: Can be treated with exercise and nutrition or with medications. • If T-score is under -2, need to ensure you are doing regular weight-bearing exercise, and getting enough vitamin D and dietary calcium. • If T-score is closer to -2.5, a medication may be considered to keep bones strong. • Bisphosphonates are most commonly prescribed medication class for treatment to prevent/reduce reabsorption of bone. Prolonged use has been linked with 2 major clinical side effects: osteonecrosis of the jaw (ONJ) 6 NR511 Final Exam Study Guide and the atypical subtrochanteric femur fracture. DE quiz question. • ONJ is rare and is associated with IV forms and not oral forms of the medication. Tx entails immediately stopping the offending agent. • Atypical femur fractures also are rare but have significant associated morbidity, and clinicians are cautioned against the chronic, uninterrupted bisphosphonate use beyond 3 to 5 years or in situations when pts report mild thigh discomfort while undergoing tx. • The core treatment options for osteopenic patients involve early education on how to achieve and maintain healthy bone mass levels and extensive education and counseling on the relevant social, environmental, and lifestyle risk factors that compromise bone health. General consensus favors pharmacologic treatment in a patient with spine or hip fractures in addition to a documented low BMD. Treatment recommendations vary for other nonvertebral fractures and include the following: • The National Osteoporosis Society (NOS) recommends starting treatment in all postmenopausal women with a history of any fragility fracture • The National Osteoporosis Foundation (NOF) recommends performing DXA scans on patients sustaining nonvertebral fragility fractures, and the decision to treat or not with pharmacotherapy is based on the patient’s t-score; patients considered to be osteopenic (tscore between -1 and -2.5) are not started on drugs. Pharmacotherapy agents work through either anti-resorptive or anabolic means. Bisphosphonates are the most commonly prescribed medication class. These drugs are divided into non-nitrogen and nitrogen-containing compounds. The latter are considered first-line therapy. The nitrogen-containing compounds inhibit farnesyl pyrophosphate synthase and ultimately inhibit osteoclast resorption and induce osteocyte apoptosis. Common agents include: • Alendronate may reduce the rate of hip, spine, and wrist fractures by 50% • Risedronate may reduce vertebral and nonvertebral fractures by 40% over three years • IV zoledronic acid reduces the rate of spine fractures by 70% and hip fractures by 40% over three years Other Medication Classes • Conjugated estrogen-progestin hormone replacement (HRT) • Estrogen-only replacement (ERT) 7 NR511 Final Exam Study Guide • Salmon calcitonin (Miacalcin, Fortical) • Selective estrogen receptor modulators (Raloxifene) - Raloxifene is an agonist to estrogen receptors on bone and reduces osteoclast resorption • Anabolic (Teriparatide) - Teriparatide is a recombinant form of parathyroid hormone (PTH) that stimulates osteoblasts to produce more bone. Teriparatide is now FDA approved for osteoporosis treatment in males and females • RANKL inhibitors (Denosumab) - Denosumab is a monoclonal Ig2 that targets RANKL and inhibits its ability to bind to RANK and results in the inhibition of osteoclast activation • The t-score is measured in standard deviations and reflects the difference between the patient's measured BMD and the mean value of BMD in healthy, young, matched controls (30- year-old women). By definition, a normal BMD measurement is within one standard deviation of the young adult mean. The WHO defines t-scores between -1 and -2.5 as osteopenic and scores below -2.5 as osteoporotic. Greater than -2.5 means osteoporosis. The z-score is also measured in standard deviations, but the z-score is compared to a healthy, age-matched control group. The z-score is most clinically relevant when obtaining a DXA scan in younger patients when secondary osteoporosis is being considered. A z-score less than -1.5 warrants a comprehensive secondary osteoporosis workup. • Standard laboratory workup includes checking calcium, phosphorus, albumin, alkaline phosphatase, liver function tests, creatinine (serum and urine), 25 hydroxyvitamin D, TSH and free T4, and intact PTH levels. Males should have a free testosterone level checked to rule out hypogonadism. • The WHO created a fracture risk assessment tool (FRAX score) to predict the 10-year risk of sustaining a hip or other major osteoporotic fracture. These other major fragility fractures include fractures of the spine, wrist, forearm, or humerus. The assessment includes 12 questions weighted by the relative risk associated with a future fragility fracture event. Assessment includes age, sex, personal history of fracture, low BMI, oral steroid use, secondary osteoporosis, parental history of hip fracture, smoking status and alcohol intake. In addition, optional BMD measurement values can be included from a prior DXA scan (if available) to 8 NR511 Final Exam Study Guide provide a more comprehensive score report. Obesity is a predisposing factor, as is osteoporosis 9. Assessment and management of gout Persons from the United States, the Pacific Islands, and countries with abundant lifestyles have an increased incidence of gout. Gout is more prevalent in African American men. The increased incidence of gout in older adults has been associated with an increased use of diuretics – HCTZ DEQ. Patients with gout may experience an acute attack with rapid fluctuations of serum urate levels. Surgery, dehydration, binge alcohol consumption, emotional stress, infections, diuretics, and uricosuric drugs can all cause rapid fluctuations in serum urate levels. Causes of primary gout include idiopathic inborn errors of purine metabolism, decreased renal clearance of uric acid, and specific enzymatic defects such those resulting in Lesch-Nyhan syndrome and glycogen storage disease. Secondary causes of gout include other disease processes and medications, such as thiazide diuretics, that result in an overproduction or underexcretion of uric acid. The patient will present during an acute attack with pain, tenderness, erythema, and swelling of the affected joints. the joint most frequently affected is the first metatarsophalangeal joint of the great (big) toe; however, the midfoot, knees, fingers, wrists, and elbows may also be affected. The typical presentation is excruciating pain that awakens the patient at night. Patients often describe the pain as throbbing, crushing, and pulsating. The pain is not relieved by rest or positional changes and prevents weight-bearing on the affected limb. Often the patient cannot tolerate anything coming in contact with the affected joint—even bed clothing touching the limb can be extremely painful. The clinical presentation and medical history findings are often sufficient to diagnose gout. A definitive diagnosis is only made with identification of sodium urate crystals in the aspirated fluid from affected joints. The goals of clinical management are to terminate an acute attack, prevent future attacks, normalize hyperuricemia, and prevent potential complications of urate deposits. Management of gout includes pharmacological treatment of acute attacks and longterm medical and pharmacological treatment of hyperuricemia. Acute management of gout includes generalized rest, elevation and immobilization of affected joints, and pharmacological 9 NR511 Final Exam Study Guide treatment. The initial medication of choice for acute gout attacks is an NSAID. Colchicine is an effective medication to terminate an acute attack of gout if administered within 36 hours of the initial onset of symptoms. Corticosteroids can provide dramatic systematic relief and can be administered orally, intramuscularly, or intra-articularly. The long-term management of gout includes pharmacological agents, dietary modifications, activity evaluation, and education regarding the prevention of gout. Patients with extensive or large tophi may benefit from surgical excision of these lesions. Physical activity must be restricted during an acute gout attack, and bedrest should be maintained for 24 hours following an acute attack. The joint should be immobilized; if a lower extremity is involved, no weight-bearing should be allowed during the acute attack. During intercritical periods, physical therapy may be indicated to maintain or improve function. Hot compresses may promote comfort after an acute attack but should not be instituted until the acute pain subsides, usually 24 to 72 hours after the initiation of therapy. The patient should apply heat for 20 minutes two to three times daily through the use of moist heating pads, warm showers and baths, or moist towels heated in a microwave. Relief may also be obtained using ice packs during an acute attack. Patients should be instructed to apply packs for only 10 to 20 minutes sessions at a time to avoid thermal damage to the skin; ice packs should be discontinued if pain is not relieved. Long-term management includes dietary moderation of purine-containing foods (limited to no more than one to two servings of purinerich foods per day), moderating alcohol intake, maintaining weight, and sufficient physical activity to maintain joint mobility during quiescent periods between gout flares. 10. Medication management for acute vs. chronic gout Acute-rest, elevation and immobilization. NSAIDS, colchicine (onset of symptoms less than 36 hours), and corticosteroids. Avoid aspirin. Avoid excessive alcohol. Avoid purine-rich foods. Chronic- uric acid secretion 1,000 mg/24 hrs: probenecid. Uric acid secretion 1,000mg/24 hrs: allopurinol. Colchcine. 11. Dietary restrictions for gout Restrict purine foods, (Examples • All meats and seafoods (especially organ meats such as liver, kidneys, and sweetbreads [thymus, pancreas]) • Meat extracts and gravies • Yeast and yeast extracts (brewer’s and baker’s) • Beer and alcoholic beverages • Beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, and mushrooms • Mussels and scallops • Anchovies, herring, and sardines • Trout, haddock, mackerel, and tuna 12. Signs and symptoms Hyperthyroidism: inverse (low TSH, High T4) 10 NR511 Final Exam Study Guide and management of thyroid disorders • excessive secretion and synthesis of one or both of the thyroid hormones thyroxine (T4) and triiodothyronine (T3) • Risk factors: Women age 20-40 • Causes: • Graves’ disease is the most common cause of spontaneous hyperthyroidism. It is an autoimmune disorder characterized by autoreactive, agonistic antibodies to the TSH receptor • Graves’ disease accounts for 80% to 90% of hyperthyroid cases • Subacute thyroiditis is the most common cause of thyrotoxicosis, accounting for 15% to 20% of cases. Characterized by glandular inflammation and follicular cell destruction, viral etiology, frequently occurring following an acute viral infection. • Toxic multinodular goiter (Plummer disease) is as common as subacute thyroiditis, more common in other parts of the world where dietary iodine deficiency is prevalent. • A tumor of the pituitary gland causing hypersecretion of TSH (thyrotropin) is a rare cause of hyperthyroidism • S/S: Anxiety, nervousness, diaphoresis, fatigue, heat intolerance, palpitations, weight loss, and insomnia. In situations in which the thyroid tissue has become enlarged, the patient may complain of fullness or pressure in the neck. Additional symptoms include weakness, exercise intolerance, tremors, lower extremity edema, weight loss in the presence of an increased appetite, menstrual irregularities, frequent bowel movements or diarrhea, and exertional dyspnea. Eye complaints include blurred vision, proptosis (downward displacement of the eyeball), photophobia, and double vision. Patients may also report that they are unable to concentrate, extremely irritable, and emotionally labile • clinical manifestations of thyrotoxicosis, which include palpitations, diaphoresis, heat intolerance, and anxiety • Testing: sensitive serum TSH assay, measurement of T4 and T3 levels, Graves’ disease, antithyroglobulin and antimicrosomal antibodies are elevated A 24-hour radioactive iodine uptake (RAIU) test can differentiate Graves’ disease from subacute thyroiditis and toxic nodular goiters, thyroid ultrasound -subabute thyroiditis – low uptake - Graves – rapid uptake • Treatment: beta blocker initially, radioactive iodine therapy, Two antithyroid drugs are 11 NR511 Final Exam Study Guide used—propylthiouracil (PTU) and methimazole (MMI), ablation or surgery ----- Hypothyroidism: • Primary: 95% of patients with hypothyroidism, dysfunction or atrophy of the thyroid gland • Central: thyroid dysfunction is caused by failure of the pituitary gland, the hypothalamus, or both, • Secondary: failure of the pituitary gland to secrete adequate amounts of TSH • Tertiary hypothyroidism: inadequate secretion of thyrotropin-releasing hormone (TRH) by the hypothalamus or failure of TRH to activate its cognate receptors within the pituitary gland • Causes: atrophy (probably autoimmune), TSH receptor–blocking antibodies, Chronic autoimmune thyroiditis (Hashimoto’s disease) Amiodarone, External radiation Status—postradioiodine (131I) treatment Status—post-thyroidectomy Infiltrating disorders: malignancy, granulomatous disease, Thyroid dysgenesis • S/S: early symptoms are often subtle and nonspecific, fatigue, dry skin, slight weight gain, cold intolerance, constipation, and heavy menses. Myalgia, muscle cramps, headaches, and weakness, very dry skin, coarse hair, loss of lateral eyebrows, alopecia, hoarseness, continued weight gain, slight impairment in mental ability, depression, decreased libido, decreased GI motilitiy and hypersomnia. patients with autoimmune thyroid disease and atrophic gastritis who also present with pernicious anemia • Testing: measuring serum TSH. TSH and FT4, antithyroid antibody titers—either for antimicrosomal (anti-TPO) antibodies or antithyroglobulin antibodies • Side note: Medications such as metoclopramide (Reglan) increase TSH levels. Dopamine (Intropin), glucocorticoids, NSAIDs, and somatostatin decrease TSH levels. Other medications, such as phenytoin (Dilantin), amiodarone (Cordarone), and lithium carbonate, can also affect thyroid function tests. Smoking (nicotine) also impacts thyroid hormone levels. These medication and chemical exposures act via a number of mechanisms to affect thyroid function. A drug may bind with albumin and displace thyroid hormone off carrier proteins, or it may 12 NR511 Final Exam Study Guide prevent albumin from binding with T3 or T4, in each case resulting in more active hormone in circulation. Some drugs may cause an upregulation in metabolic processing proteins (i.e., different cytochrome P oxidase isomers), which normally inactivate thyroid hormones; thus, their upregulation can lead to more rapid processing of thyroid hormones and, in turn, affect TSH levels. • Treatment: synthroid or levothyroxine 13. Thyroid screening tests, confirmatory tests and monitoring There are differing opinions on whether to screen for thyroid disorders in asymptomatic adults. Recommendations of 6 Organizations Regarding Screening of Asymptomatic Adults for Thyroid Dysfunction Organization Recommendation American Thyroid Association Women and men 35 years old should be screened every 5 years. American Association of Clinical Endocrinologists Older patients, especially women, should be screened. Academy of American Family Physicians Patients 60 years old should be screened. American College of Physicians Women 50 years with an incidental finding suggestive of symptomatic disease should be evaluated. U.S. Preventative Services Task Force There is insufficient evidence for or against screening. Royal College of Physicians of London Screening of the healthy adult population is unjustified. Adapted from the ATA/AACE Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocrine Practice, 18(6). Although there is no consensus about population screening in healthy individuals, there is evidence to support screening in the following at-risk populations, including those with  autoimmune disorders;  pernicious anemia;  first-degree relative with Auto-Immune thyroid disease;  history of neck radiation; 13 NR511 Final Exam Study Guide  history of prior thyroid surgery or dysfunction;  abnormal thyroid examination; and  psychiatric disorders. Additional diagnoses that support thyroid screening are listed in Table 9 of the ATA/AACE Clinical Practice Guidelines. National organizations differ in their recommendations for routine screening in asymptomatic patients. In 2004 the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence for or against routine screening for thyroid disease in adults without symptoms, and the USPSTF has not updated this recommendation. If the patient is symptomatic or in a high-risk category, such as having a family history of thyroid disease or previous history of thyroid disease or autoimmune disorders, screening is appropriate. The initial screening tests for suspected hyperthyroidism are measurement of the serumsensitive TSH assay to detect suppressed levels in the setting of elevated thyroid hormones, T4 and T3. Laboratory protocols that add free thyroxine immunoassay (FT4) and T3 if the TSH is low can avoid additional blood draws and expense. If the protocol is not in place, an FT4 and T3 should be tested next. The sensitive TSH assay has a functional sensitivity of 0.02 mcg/dL or less, although units for this test are typically expressed as mIU/L or mcIU/mL. Confirmatory tests hyperthyroid: A 24-hour radioactive iodine uptake (RAIU) test can differentiate Graves’ disease from subacute thyroiditis and toxic nodular goiters, thereby refining treatment recommendations. DEQ – increased uptake It identifies areas of increased and decreased thyroid function, often termed hot and cold spots, within the gland. Patients with toxic nodular goiter and Graves’ disease have a high RAIU, whereas in subacute thyroiditis, iodine uptake is low. 14 NR511 Final Exam Study Guide A thyroid scan is critical to determining functionality of any dominant thyroid nodule in a patient presenting with thyrotoxicosis, because cold nodules are highly suspicious for concomitant malignancy and must be evaluated further. An ultrasound of the thyroid will assist in differentiating a cyst from a nodule A fine-needle biopsy is the preferred initial diagnostic technique for evaluation of thyroid masses, particularly solid masses, to rule out malignancy. Magnetic resonance imaging is the preferred test to assess for ophthalmopathy resulting from Graves’ disease Monitoring hyperthyroidism: Before initiation of antithyroid therapy, a baseline complete blood count and liver function tests including hepatic aminotransferases (aspartate aminotransferase, alanine aminotransferase) should be obtained. During therapy, the white blood cell count is checked every 2 weeks during the first month and then every 4 to 6 months thereafter. Liver enzymes should be evaluated every 3 to 6 months. Radioactive Iodine Radioactive iodine–131 (131I; Iodotope) is the treatment of choice for hyperthyroidism in the United States, especially in middle-aged or older adults. Typically, a 24- hour radioiodine uptake dose of 75 to 200 mcCi per gram of estimated thyroid tissue is administered orally Women receiving radioactive iodine therapy should refrain from becoming pregnant for 4 months after therapy. T4 levels need to be checked monthl