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Surgery Subspecialty [ENDOCRINE]

Thyroid Nodule Simplified

In a hyperthyroid patient nodules are almost never cancer. Do a
RAIU to show an increased uptake after ensuring the thin patient
with heat intolerance, weight loss, and diarrhea is indeed
hyperthyroid with a TSH+T4. If the nodule is “hot” it can be resected
or hit with radioiodine ablation. There’s almost no need to even
biopsy it. However, in a euthyroid patient nodules can be cancer. Do
a TSH/T4 to show they’re euthyroid, then do an ultrasound guided
FNA to get a diagnosis. FNA is the mainstem of management. If
for cancer proceed to Thyroidectomy. If it’s for cancer but you
aren’t sure, repeat the FNA. If it’s definitely , you can do a watch
and wait pattern. Follicular cancer can be treated with radioactive

If it’s been established that hyperparathyroidism is the cause of
↑PTH, ↑Ca, ↓P - not from mets to bone or another condition - the
affected gland needs to be removed. Usually there’s a singular
adenoma, resulting in a single gland resection. Use the Sestamibi
scan to find which one is enlarged. Take caution after resection for
hypocalcemia (perioral tingling, Chvostek Sign, Trousseau sign); as
the atrophied glands kick in they may not produce enough initially.

Zollinger-Ellison (Gastrin)
In a patient with persistent, virulent peptic ulcer disease and Gastrin: 4 digits = Gastrinoma
diarrhea consider this gastrinoma. First measure serum gastrin Gastrin: 3 digits = probably on PPI
then do a secretin test (showing a paradoxical increase). Identify the Gastrin: 2 digits = normal
tumor with a CT scan or SRS scintigraphy. Cut it out.

Insulinoma (Insulin) Insulin C Peptide Sulfonylurea

In a patient with repeated hypoglycemic states, especially if they’re screen
fasting, first consider factitious then insulinoma. To rule out Insulinoma ↑ ↑
factitious, get a C-peptide assay; it’s normal or low in factitious, Sulfonylurea ↑ ↑
elevated in insulinoma. A sulfonylurea screen rules our sulfonylurea Insulin ↑ ↓
screen. A CT scan locates the adenoma so it can be resected. Injection

In a patient with migratory necrolytic dermatitis (they’ll often just
tell you this) and a touch of DM, get an elevated glucagon level. Do
a CT to find it, then try to resect it (often, this fails).

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