Exam Study Notes

Hyperthyroidism & Hypothyroidism

  • Differences:

    • Thyroid Hormones (T3 & T4): Affect the basic metabolic rate.
    • Hypothyroidism: Deficiency in production & release of T3 & T4.
      • Causes:
        • Iodine deficiency.
        • Thyroiditis (autoimmune; autoantibodies lead to the destruction of thyroid cells).
        • Post-treatment (e.g., thyroidectomy) of hyperthyroidism can result in hypothyroidism.
        • Congenital.
    • Hyperthyroidism: Excess of T3 & T4 (HIGH).
      • Causes:
        • Graves’ disease – Autoimmune antibodies (TSI) stimulate TSH receptors on the thyroid gland.
        • Toxic multinodular goiter.
        • CA (Cancer) thyroid.
        • Excess in exogenous thyroid hormone (thyroxine replacement Tx).

  • Signs & Symptoms (S&Sx):

    • Hypothyroidism:
      • Cold intolerance.
      • Decreased sweating.
      • Cardiovascular (CV): Slow heart rate (bradycardia).
      • Gastrointestinal (GI): Low motility leading to constipation.
      • Weight gain.
      • Goiter (overstimulation by TSH from pituitary).
      • Central Nervous System (CNS): Poor memory, slow thinking, depression.
      • Menstruation: Irregular & heavy periods.
    • Hyperthyroidism:
      • Heat intolerance.
      • Sweating.
      • Rapid heart rate (tachycardia); irregular.
      • High motility leading to “Diarrhea”; frequent bowel movement.
      • Weight loss despite good appetite.
      • Goiter (presence of nodules in the thyroid gland).
      • Irritable; anxiety.
      • Light; short periods.
      • Muscle weakness; osteoporosis.
      • Protruding eyeballs (Graves’ disease).

  • Treatment (Tx):

    • Hypothyroidism:
      • Levothyroxine (natural form of thyroid hormone, T4) replacement.
      • Iodine supplement.
    • Hyperthyroidism:
      • Graves’ disease: Antithyroid drugs (inhibit the synthesis of thyroxine).
      • Removal or destruction of thyroid tissue: Surgery (thyroidectomy); radioactive iodine.

  • Diagnosis (Dx):

    • Hypothyroidism:
      • Thyroid Function Test (TFT): ↑ TSH; ↓ T3 / T4.
      • Imaging: Ultrasound (US).
      • Test for autoantibodies against the thyroid gland.
    • Hyperthyroidism:
      • ↓ TSH; ↑ T3 / T4.
      • US.
      • Radioactive iodine (RI) uptake test.
      • Test for autoantibodies against TSH receptor (TSI).

Diabetes Mellitus (DM)

  • Types:

    • Type 1 (T1DM)
    • Type 2 (T2DM)

  • Causes:

    • T1DM (IDDM):
      • Onset: Childhood.
      • Autoimmune condition with genetic predisposition + environmental factors (e.g., viral infections).
    • T2DM (NIDDM):
      • Onset: Adulthood.
      • Metabolic syndrome: Overweight/obese.

  • Pathophysiology:

    • T1DM:
      • Absolute deficiency in insulin due to the destruction of Beta cells of the pancreas.
    • T2DM:
      • Relative deficiency of insulin.
      • Insulin resistance / decreased sensitivity of insulin-dependent cell activities (despite higher normal production of insulin).
      • Decrease in production of insulin.
    • Insulin-Dependent Cellular Activities:
      • Glucose uptake by skeletal muscles, fat/adipose tissue (fat/adipose cells) & Utilization of glucose by skeletal muscles, fat tissues & liver → Hyperglycemia \Rightarrow glucosuria (presence of glucose in urine due to incomplete reabsorption of glucose by kidneys) \Rightarrow Ketone bodies formation \Rightarrow Breakdown of protein.
      • Hyperglycemia \Rightarrow Microvascular complications \Rightarrow kidneys, nerves & macrovascular complications (heart disease, stroke, peripheral vascular diseases, etc.).

  • Signs & Symptoms (S&Sx):

    • T1DM & T2DM:
      • Hyperglycemia.
      • Glucosuria \Rightarrow polyuria (osmotic diuresis); dehydration; polydipsia.
    • T1DM:
      • Weight loss (glucose lost) \Rightarrow polyphagia.
      • Poor growth & development if not properly treated with insulin.
    • Both T1DM & T2DM:
      • UTI; genital itch
      • Neuropathy (nerve pain; abnormal sensations); Retinopathy (retina = nerves \Rightarrow vision).
      • Poor wound healing.
      • Poor immune response.
      • Foot infections \Rightarrow gangrene \Rightarrow amputations.

  • Diagnosis (Dx):

    • Tests on blood glucose levels (Fasting blood glucose - ~ 8 hr fasting; Post-prandial; 2 hr after meals) & related glycation with cellular molecules (HbA1c).
    • Oral glucose tolerance test (OGTT).

  • Treatment (Tx):

    • T1DM:
      • Insulin replacement therapy \Rightarrow Insulins of different onset (rapid onset) & duration of action \Rightarrow Try to mimic physiologic insulin response to glucose intake from diet.
    • T2DM:
      • Insulin replacement therapy.
      • Oral antidiabetic drugs to:
        • Stimulate secretion of insulin (e.g., sulfonylureas).
        • Increase sensitivity of insulin (e.g., metformin).
        • Increase excretion of urinary glucose (e.g., SGLT1 inhibitors).

Osteoporosis

  • Causes and risk factors
  • Signs and Symptoms
  • Diagnostic methods
  • Treatment options

Gout vs. Rheumatoid Arthritis (RA) vs. Osteoarthritis (OA)

  • Causes & Risk Factors:

    • Gout:
      • KEY: Uric acid (the end metabolic product of purines – Adenine (A) & guanine (G) found in nucleic acids, RNA & DNA
      • Overproduction or under-secretion of uric acid.
      • Purine-rich foods.
      • Kidney failure \Rightarrow under-secretion.
    • RA:
      • Autoimmune arthritis + Extra-articular involvements (heart, rheumatoid nodules, etc.).
    • OA:
      • Degeneration of cartilage that normally cushions the articulating bones.
      • Overweight (stress to the weight-bearing joints).
      • Repeated joint injury.

  • Pathophysiology:

    • Gout:
      • Hyperuricemia \Rightarrow Deposition of urate (uric acid) crystals in the affected joint.
      • Attraction of inflammatory cells to the joint & attempt to remove the crystals by inflammatory cells.
      • Intense inflammation \Rightarrow S&Sx.
    • RA:
      • Citrullination of proteins \Rightarrow Auto-Immune response.
      • Attraction of inflammatory cells to the joint \Rightarrow antibodies, response by T cells.
      • Destruction of the joint tissues (cartilage, bones) by invasion of inflamed synovium.
      • Permanent change in shape & functions of the affected joints.
    • OA:
      • Degradation by … from Inflammatory response within cartilage.
      • Rubbing of the 2 bones \Rightarrow bone erosion \Rightarrow pain & new bone growth (bone spurs / osteophytes).

  • Signs & Symptoms (S&Sx):

    • Gout:
      • Acute during gouty attacks: Severe pain, swelling, redness, tenderness even from light touch.
      • Chronic: Presence of tophi (singular: tophus) in soft tissues.
    • RA:
      • Pain
      • Deformity of joints \Rightarrow range of motion / flexibility of joints & loss of joint functions.
      • Fatigue (anemia).
      • Weakness.
      • Rheumatoid nodules.
    • OA:
      • Pain & stiffness
      • Range of motion
      • Crepitus (grinding sensation when the affected joint moves).

  • Diagnosis (Dx):

    • Gout:
      • Elevated uric acid levels in the blood.
      • Joint fluid examination.
      • Imaging: X-ray, US, DECT.
    • RA:
      • Anti-CPP antibodies / RF (antibodies).
      • Inflammatory indices: CRP; ESR.
      • Joint fluid exam.
      • CBC: Anemia.
      • Imaging: X-ray; MRI.
      • Lab tests.
    • OA:
      • Arthroscopy
      • X-ray; MRI

  • Treatment (Tx):

    • Gout:
      • Lifestyle.
      • Acute: Anti-inflammatory & pain relief
        • Colchicine (anti-inflammatory).
        • Corticosteroid (anti-inflammatory) / NSAID (anti-inflammatory & pain killing).
      • Chronic: Reduction of uric acid
        • Inhibition of uric acid production.
        • Increase urinary excretion.
    • RA:
      • Inflammation & Pain relief – SHORT term
        • NSAID / Corticosteroids
      • Disease-modifying that helps to slow down or even prevent permanent joint damage – Long- term
        • DMARDs (e.g., methotrexate).
        • Biologics for inhibiting different inflammatory cytokines.
      • Surgery – Different methods
    • OA:
      • Pain relief
      • Drug & non-drug
      • Weight control if overweight
      • Surgery – Different methods

Uterine Fibroid (Leiomyoma)

  • Uterine Fibroid (子宮肌瘤)
    • Risk factors
    • Signs and symptoms
    • Diagnostic methods
    • Treatment options

Cervical Cancer

  • Cervical Cancer (子宮頸癌)
    • Risk factors
    • Signs and symptoms
    • Diagnostic methods
    • Treatment options
    • Preventive measures

Breast Cancer

  • Breast Cancer (乳癌)
    • Causes
    • Risk factors
    • Signs and symptoms
    • Diagnostic tests
    • Treatment options

Benign Prostatic Hyperplasia (BPH)

  • Benign Prostatic Hyperplasia (BPH) (良性前列腺增生)
    • Signs and symptoms/ Clinical manifestations of BPH
    • Diagnostic tests for BPH

Uterine Fibroid (Leiomyoma), Cervical CA, Breast CA Comparison

  • Locations:

    • Uterine fibroid: Uterus = Myometrium (muscle layer of the uterus).
    • Cervical CA: Cervices of the Uterus.
    • Breast CA: Epithelium cells of the breast tissue.

  • Cause:

    • Uterine fibroid: --
    • Cervical CA: HPV (high risk strains, e.g., HPV 16 & 18).
    • Breast CA: Growth factors, including estrogen, etc. Genetic mutations: Oncogene (e.g., HER2, c- Myc) & tumor suppressor genes (e.g., p53, BRCA1, BRCA2).

  • Risk Factors:

    • Uterine fibroid: Estrogen/progesterone fluctuation.
    • Cervical CA: HPV + other risk factors (such as sexual activity).
    • Breast CA: Reproductive factors, Hormonal factors, Environmental, familial & genetics, Others.

  • Signs & Symptoms (S&Sx):

    • Uterine fibroid: Depending on the type (locations of the fibroid & sizes). Uterine bleeding, Pain, Related symptoms related to adjacent organs (bladder & rectum) due to pressure from the fibroid mass, Infertility.
    • Cervical CA: Staging: I, II, III, & IV. S&Sx of Metastasis - Organ/tissue involved. Vaginal bleeding – Different manifestations. Discharge; pain; anemia. Related symptoms related to adjacent organs (bladder & rectum) in advanced stages (spread).
    • Breast CA: Palpable mass in breast. Physical changes in breast, such as … Pain.

  • Diagnosis (Dx):

    • Uterine fibroid: Medical Hx, Physical examination – Bimanual pelvic exam, Hysteroscopy; Imaging: US, MRI.
    • Cervical CA: PAP test / HPV test, Colposcopy, CT & PET scan for metastasis, Etc.
    • Breast CA: Imaging: Mammogram, US. Biopsy. Status of Hormone receptors & HER2 – Molecular profiling.

  • Treatment (Tx):

    • Uterine fibroid: Conservative Tx in early stage. Medical Tx - Hormonal, NSAID, Tranexamic acid. Surgery - Different methods.
    • Cervical CA: Solid CA \Rightarrow Surgery (depending on the stage of the CA) \Rightarrow Different methods & extents \Rightarrow Radiotherapy \Rightarrow Chemotherapy \Rightarrow Palliative care (to keep the patient as comfortable as possible) when cure is not possible.
    • Breast CA: Solid CA \Rightarrow Surgery – Different extents \Rightarrow Radiotherapy \Rightarrow Chemotherapy \Rightarrow Hormonal therapy (e.g., Tamoxifen, Aromatase inhibitors, such as letrozole) \Rightarrow Targeted therapy (e.g., HER2) \Rightarrow Palliative care.

  • Prevention:

    • Uterine fibroid: --
    • Cervical CA: Reduction of sexual contacts. Screening (early detection). Vaccination against HPV (most effective is before contraction).
    • Breast CA: --