MEGAN CHAN, PGY-1UHCMC 2015

Thyroid Cases

Guess the Diagnosis?

TSH Free T4 T3 Diagnosis

↓ ↑ ↑ Primary hyperthyroidism

↑ ↑ ↑ Central hyperthyroidism

↓ Normal Normal Subclinical hyperthyroidism

↓ Normal ↑ T3 thyrotoxicosis

↑ ↓ ↓ Primary hypothyroidism

↓ ↓ ↓ Central hypothyroidism

↑ Normal Normal Subclinical hypothyroidism

Normal ↑ ↑Exogenous thyroid hormone

Case 1

44 y/o male is involved in a motor vehicle collision and sustains multiple injuries to the face, chest and plevis. He is unresponsive on the field and is intubated for airway protection. Pt is admitted to the ICU, stabilized and undergoes successful open reduction & internal fixation of the right femur and right humerus. After he returns to the ICU, his TSH is 0.3 mU/L and the total T4 level is normal. T3 is 0.6 μg/dL. What is the most appropriate next management step?A. Initiation of levothyroxineB. Radionucleotide uptake scanC. Thyroid ultrasoundD. ObservationE. Initiation of prednisone

Case 1

What is the most appropriate next management step?A. Initiation of levothyroxineB. Radionucleotide uptake scanC. Thyroid ultrasoundD. ObservationE. Initiation of prednisone

Sick-euthyroid syndrome can occur in any acute, severe illness. TSH/T4/T3 abnormalities are thought to result from release of cytokines in response to severe stress. The most common hormone pattern is low total and unbound T3 as peripheral conversion of T4 to T3 is impaired. This is thought to be evolutionarily helpful as lowering the most active thyroid hormone would limit catabolism in starved or ill patients. T4 may be decreased in very sick patients. Thyroid function will return to normal in weeks to months as the patient recovers.

Case 2

29 y/o woman presents to your clinic complaining of difficulty swallowing, sore throat, and tender swelling in her neck. She has also noted fevers intermittently over the past week. Several weeks prior to her current symptoms she experienced symptoms of an URI. She has no PMHx. On exam, she is noted to have a small goiter that is painful to the touch. Her oropharynx is clear. Labs show WBC of 14.1 with normal diff, ESR 53, TSH of 21. Thyroid antibodies are negative. What is the most likely diagnosis?A. Autoimmune hypothyroidismB. Cat-scratch feverC. Ludwig’s anginaD. Subacute thyroiditis

Case 2

What is the most likely diagnosis?A. Autoimmune hypothyroidismB. Cat-scratch feverC. Ludwig’s anginaD. Subacute thyroiditis

What is the most appropriate treatment for this patient?E. Iodine ablation of the thyroidF. Large doses of AspirinG. Local radiation therapyH. No treatment necessaryI. Propylthiouracil

Case 2

What is the most appropriate treatment for this patient?A. Iodine ablation of the thyroidB. Large doses of AspirinC. Local radiation therapyD. No treatment necessaryE. Propylthiouracil

Subacute Thyroiditis

Aka Quervain’s thyroiditis, granulomatous thyroiditis, viral thyroiditis Presents with fever, constitutional symptoms, & painful enlarged

thyroids. Peak incidence: 30-50 y/o, females > males Multiple viruses have been implicated, but none identified as the trigger 3 phase illness:

1st– Thyroid inflammation follicle destruction release of thyroid hormones Thyrotoxicosis Low TSH, high T4 & T3, radioiodine uptake is low/undetectable.

2nd—Thyroid is depleted of hormone Hypothyroidism Elevated TSH, low free T4, radioiodine uptake returns to normal.

3rd—Recovery phase: decreased inflammation follicles heal & regenerate thyroid hormone (4-6 months later)

Usually self-limited, benign Treatment:

Mild sxs: Large doses of Aspirin (600mg q4-6hrs), NSAIDs Severe sxs: Steroid taper May require low-dose levothyroxine

Case 3

62 y/o man presents to the ED with chest pressure and feeling “like my heart is fluttering inside my chest.” He experienced similar symptoms 1 month ago that resolved spontaneously. He did not seek medical attention at that time. He has no significant PMHx. On ROS he notes some recent weight loss despite an increase in appetite and excessive sweating. On exam, HR is irregular at 140-150 beats/min. BP is 135/55. He is admitted and screening tests reveal and undetectable TSH level.

Case 3

Which of the following statements is true?A. 50% of hyperthyroid patients will convert from

Afib to NSR with thyroid management alone.B. A firm, small thyroid on exam would be

compatible with a diagnosis of Graves’ disease.C. Afib is the most common cardiac manifestation

of hyperthyroidism.D. His excessive sweating is likely not related to

hyperthyroidisim.E. Hyperthyroidism leads to a high-output state for

the heart, narrowing the pulse pressure.

Case 3

Which of the following statements is true?A. 50% of hyperthyroid patients will convert from Afib to NSR with

thyroid management alone.B. A firm, small thyroid on exam would be compatible with a diagnosis of

Graves’ disease.C. Afib is the most common cardiac manifestation of hyperthyroidism.D. His excessive sweating is likely not related to hyperthyroidisim.E. Hyperthyroidism leads to a high-output state for the heart, narrowing the

pulse pressure.

Common signs of thyrotoxicosis include tachycardia (most common cardiac abnormality), Afib, tremor, goiter, and warm, moist skin. Common symptoms include hyperactivity, dysphoria, irritability, heat intolerance, excessive sweating and fatigue. Weight loss occurs frequently; however, some pts will gain weight as they typically have marked increase in appetite. The arrhythmias are a manifestation of a high-output state, which frequently leads to a widened pulse pressure and a systolic murmur. This can exacerbate underlying heart failure or CAD.

Case 3

The same patient is started on atenolol and his heart rate slows to 80 beats/min. Which of the following additional therapies is most indicated?A. DiltiazemB. MethimazoleC. LevothyroxineD. LiothyronineE. Phenoxybenzamine

Case 3

Which of the following additional therapies is most indicated?A. DiltiazemB. MethimazoleC. Levothyroxine—sometimes used in combination with antithyroid

drugs (block-replace regimen) to avoid drug-induced hypothyroidism.

D. Liothyronine (oral form of T3)E. Surgical resection

Hyperthyroidism is treated with antithyroid drugs, radioactive iodine, or thyroidectomy. Methimazole and PTU inhibit thyroid peroxidase and thus decrease production of T4 & T3. In Graves’ disease, they also reduce thyroid antibody levels. Thyroid function tests & clinical manifestations are reviewed every 3-4 weeks with dose titrated based on unbound T4. Euthyroidism usually takes 6-8 weeks.

Case 4

40 y/o female with Grave’s disease was recently started on methimazole. One month later she comes to clinic for a routine follow up. She notes some low-grade fevers, arthralgia, and general malaise. Labs show mild transaminitis and glucose of 150. All of the following are known side effects of methimazole except:A. AgranulocytosisB. RashC. ArthralgiasD. HepatitisE. Insulin resistance

Case 4

All of the following are known side effects of methimazole except:A. AgranulocytosisB. RashC. ArthralgiasD. HepatitisE. Insulin resistance

Methimazole and PTU both inhibit the function of thyroid peroxidase, reducing oxidation and organification of iodide. Rash, urticaria, fever & arthralgias are common side effects. Major side effects are rare but include hepatitis, agranulocytosis (<1%) & SLE-like syndrome.

Case 5

A patients presents to clinic with complaints of fatigue & hair loss. He has gained 6.4kg since his last clinic visit 6 months ago but notes markedly decreased appetite. On ROS, he reports not sleeping well & feels cold all the time. He is still able to enjoy his hobbies and does not believe that he is depressed. Exam reveals diffuse alopecia and slowed deep tendon reflex relaxation.

Case 5

Which of the following statements regarding the most likely diagnosis is correct?A. A normal TSH excludes secondary, but not primary

hypothyroidism.B. T3 measurement is not indicated to make the

diagnosis.C. The T3/T4 ratio is important for determining

response to therapy.D. Thyroid peroxidase antibodies distinguish between

primary and secondary hypothyroidism.E. Unbound T4 is a better screening test than TSH for

subclinical hypothyroidism.

Case 5

Which of the following statements regarding the most likely diagnosis is correct?A. A normal TSH excludes secondary, but not primary hypothyroidism.B. T3 measurement is not indicated to make the diagnosis.C. The T3/T4 ratio is important for determining response to therapy.D. Thyroid peroxidase antibodies distinguish between primary and secondary

hypothyroidism.E. Unbound T4 is a better screening test than TSH for subclinical hypothyroidism.

While hypothyroidism may be strongly suspected from history & physical exam, it is definitively diagnosed with labs. TSH should be the first test sent. A normal TSH excludes primary, but not secondary, hypothyroidism. T3 levels are normal in ~25% of patients with clinical hypothyroidism and not indicated for diagnosis. T3/T4 ratio is not helpful for diagnosis or prognosis. If TSH is low or normal & pituitary disease is suspected, a free T4 should be sent. If T4 is low, DDx includes anterior pituitary dysfxn, sick euthyroid syn, & drug effects. In subclinical hypothyroidism, TSH is the test of choice as TSH is elevated and T4 in normal. Thyroid peroxidase antibodies are present in >90% of patients with autoimmune hypothyroidism.

Case 6

A 75 y/o woman is diagnosed with hypothyroidism. She has long-standing CAD and is wondering about the potential consequences for her cardiovascular system. Which of the following statements is true regarding the interaction of hypothyroidism and the CV system?A. Myocardial contractility is increased with hypothyroidism.B. A reduced stroke volume is found with hypothyroidism. C. Pericardial effusions are rare manifestations of

hypothyroidism.D. Reduced peripheral resistance is found in hypothyroidism

and may be accompanied by hypotension.E. Blood flow is diverted toward the skin in hypothyroidism.

Case 6

Which of the following statements is true regarding the interaction of hypothyroidism and the CV system?A. Myocardial contractility is increased with hypothyroidism.B. A reduced stroke volume is found with hypothyroidism. C. Pericardial effusions are rare manifestations of hypothyroidism.D. Reduced peripheral resistance is found in hypothyroidism and may

be accompanied by hypotension.E. Blood flow is diverted toward the skin in hypothyroidism.

Hypothyroidism is associated with bradycardia & reduced myocardial contractility, thereby reducing stroke volume. Increase peripheral resistance may be accompanied by diastolic hypertension. Pericardial effusions are found in up to 30% of patients. Blood flow is directed away from the skin & thus produce cool extremities.

Case 7

38 y/o woman presents to clinic complaining of fatigue & irritability that have been worsening over the past several months. She has a history of mild intermittent asthma and hypertriglyceridemia. Exam reveals HR 105, BP 136/72, bilateral proptosis and warm, moist skin. Screening tests are sent and reveal a TSH level that is undetectable and a normal free T4.What should be the next step in diagnosis?A. Radionuclide scan of the thyroidB. Thyroid-stimulating antibody screenC. Thyroid peroxidase antibody screenD. Total T4E. Unbound T3

Case 7

What should be the next step in diagnosis?A. Radionuclide scan of the thyroidB. Thyroid-stimulating antibody screenC. Thyroid peroxidase antibody screenD. Total T4E. Unbound T3

In patients with thyrotoxicosis due to Graves’ disease, the TSH is low and total & unbound thyroid hormone levels are increased. In 2-5% of patients, only the T3 levels will be increased. In this patient with a high pre-test probability of Graves’ disease, a suppressed TSH & normal T4 supports Graves’; however, T3 should be tested to definitively make the diagnosis. Measuring thyroid antibodies will help confirm the diagnosis of Graves’ but the diagnosis can be made without them. Radionuclide scan is used to evaluate for toxic multinodular goiter and toxic adenoma.

Case 8

Which of the following is most consistent with a diagnosis of subacute thyroiditis?A. 38 y/o female with 2-wk history of painful thyroid, elevated

T4 & T3, low TSH, and an elevated radioactive iodine uptake scan.

B. 42 y/o male with history of painful thyroid 4 months ago, fatigue, malaise, low free T4 & T3, and elevated TSH.

C. 31 y/o female with a painless enlarged thyroid, low TSH, elevated T4 & free T4, and an elevated radioactive iodine uptake scan.

D. 50 y/o male with a painful thyroid, slightly elevated T4, normal TSH, and an ultrasound showing a mass.

E. 46 y/o female with 3 weeks of fatigue, low T4 & T3, and low TSH.

Case 8

Which of the following is most consistent with a diagnosis of subacute thyroiditis?A. 38 y/o female with 2-wk history of painful thyroid, elevated T4 & T3, low TSH, and an elevated

radioactive iodine uptake scan.B. 42 y/o male with history of painful thyroid 4 months ago, fatigue, malaise, low free T4 &

T3, and elevated TSH.C. 31 y/o female with a painless enlarged thyroid, low TSH, elevated T4 & free T4, and an elevated

radioactive iodine uptake scan.D. 50 y/o male with a painful thyroid, slightly elevated T4, normal TSH, and an ultrasound showing a

mass.E. 46 y/o female with 3 weeks of fatigue, low T4 & T3, and low TSH.

Recall the 3 stages of subacute thyroiditis: 1) Thyrotoxicosis—Low TSH, high T4 & T3, radioiodine uptake is low/undetectable.2) Hypothyroidism—Elevated TSH, low free T4, radioiodine uptake returns to normal.3) Recovery (4-6 months later)Patient B is in the hypothyroid stage of subacute thyroiditis.Patient A is consistent with the thyrotoxic phase except the radioiodine uptake scan should be decreased, not elevated.Patient C is more consistent with Graves’ disease.Patient D is consistent with neoplasm.Patient E is consistent with central hypothyroidism.

Case 9

A healthy 53 y/o man comes to your office for an annual physical exam. He has no complaints and has no significant medical history. He is taking an OTC multivitamin and no other medications. On exam he is noted to have a nontender thyroid nodule. His TSH is found to be low. What is the next step in his evaluation?A. Close follow-up and measure TSH in 6 months.B. Fine-needle aspirationC. Low-dose thyroid replacementD. PET followed by surgeryE. Radionuclide thyroid scan

Case 9

What is the next step in his evaluation?A. Close follow-up and measure TSH in 6 months.B. Fine-needle aspirationC. Low-dose thyroid replacementD. PET followed by surgeryE. Radionuclide thyroid scan

Thyroid nodules are found in 5% of patients and are more common with age, in women, and in iodine-deficient areas. TSH should be the first test after detection of a thyroid nodule. In the case of normal TSH, FNA or US-guided biopsy should be pursued. If the TSH is low, a radionuclide scan should be performed to determine if the nodule is the source of thyroid hyperfunction. “Hot” nodules can be treated medically, resected or ablated with radioactive iodine. “Cold” nodules should undergo FNA. 4% of nodules will be malignant, 10% suspicious for malignancy & 86% are indeterminate or benign.

Case 10

38 y/o mother of three presents to her PCP with complaints of fatigue and low energy for 3 months. She was previously healthy and was taking no medications. She does report a 5kg weight gain and severe constipation, for which she is now taking laxatives. A TSH is elevated at 25 mU/L. Free T4 is low. She is wondering why she has hypothyroidism.Which of the following tests is most likely to diagnose the etiology?A. Antithyroglobulin antibiodyB. Antithyroid peroxidase antibodyC. Radioiodine uptake scanD. Serum thyroglobulin levelE. Thyroid ultrasound

Case 10

Which of the following tests is most likely to diagnose the etiology?A. Antithyroglobulin antibiodyB. Antithyroid peroxidase antibody (TPO)C. Radioiodine uptake scanD. Serum thyroglobulin levelE. Thyroid ultrasound

The most common cause of hypothyroidism in the US is autoimmune thyroiditis, as it is a iodine-replete area. Although earlier in the disease, a radiooidine uptake scan may have shown diffusely increased uptake from lymphocytic infiltration, at this point in the disease when the infiltrate is “burned out” there is likely to be little found on the scan. Likewise, a thyroid ultrasound would only be useful for presumed multinodular goiter. TPO Abs are commonly found in autoimmune thyroditis, while antithyroglobulin Abs are less commonly found. Antithyroglobulin Abs are also found in other thyroid disorders (Graves’ disease, thyrotoxicosis) and systemic autoimmune diseases (SLE). Thyroglobulin is released from the thyroid in all types of thyrotoxicosis with the exception of thyroid disease. This patient, however, is hypothyroid.

Case 11

A 54 y/o woman with long-standing hypothyroidism is seen by her PCP for a routine evaluation. She reports feeling fatigues and somewhat constipated. Since her last visit, her other medical conditions, which include hypercholesterolemia & systemic HTN, are stable. She was diagnosed with uterine fibroids and started on iron recently. Her other meds include levothyroxine, atorvastatin, and HCTZ. Her TSH is found to be elevated at 15 mU/L. Which of the following is the most likely reason for her elevated TSH?A. Celiac diseaseB. Colon cancerC. Medication noncomplianceD. Poor absorption of levothyroxine due to ferrous sulfateE. TSH-secreting pituitary adenoma

Case 11

Which of the following is the most likely reason for her elevated TSH?A. Celiac diseaseB. Colon cancerC. Medication noncomplianceD. Poor absorption of levothyroxine due to ferrous sulfateE. TSH-secreting pituitary adenoma

An increase in TSH in a patient with hypothyroidism that was previously stable in dosing for many years suggests either a failure of taking the medication, difficulty with absorption from bowel disease, or medication interaction. Pts with normal body weight taking >200μg of levothyroxine per day with continued elevated TSH strongly suggests noncompliance. Other causes of increased thyroxine requirements include malabsorption (celiac disease, small bowel resection), estrogen therapy, & drugs that interfere with T4 absorption (ferrous sulfate, cholestyramine) or clearance (lovastatin, amiodarone, carbamazepine, phenytoin).

Case 12

87 y/o woman is admitted to the MICU with depressed level of consciousness, hypothermia, sinus bradycardia, hypotension and hypoglycemia. She was previously healthy with the exception of hypothyroidism and systemic HTN. Her family mends that she was not taking any of her medications due to financial difficulties. There is no evidence of infection on exam, urine microscopy, or CXR. Her labs are notable for mild hyponatremia and glucose of 48. TSH is >100 mU/L.

Case 12

All of the following statements regarding this condition are true EXCEPT:A. External warming is a critical feature of therapy

in patients with a temperature above 34º C.B. Hypotonic IV solutions should be avoided.C. IV levothyroxine should be administered with IV

glucocorticoids.D. Sedation should be avoided if possible.E. This condition occurs almost exclusively in the

elderly and often is precipitated by an unrelated medical illness.

Case 12

All of the following statements regarding this condition are true EXCEPT:A. External warming is a critical feature of therapy in patients with

a temperature above 34º C.B. Hypotonic IV solutions should be avoided.C. IV levothyroxine should be administered with IV glucocorticoids.D. Sedation should be avoided if possible.E. This condition occurs almost exclusively in the elderly and often is

precipitated by an unrelated medical illness.

The patient has myxedema coma. This condition of profound hypothyroidism most commonly occurs in the elderly, often with a precipitating condition (e.g. MI, infection). Management includes IV levothyroxine and glucocorticoids due to impaired adrenal reserve in severe hypothyroidism. Care must be taken with rewarming as it may precipitate cardiovascular collapse. Therefore, external warming is indicated only if temperature is below 30ºC. Hypertonic saline & glucose may be used if hyponatremia or hypoglycemia is severe; however hypotonic solutions should be avoided as this may worsen fluid retention.

Case 13

29 y/o woman is evaluated for anxiety, palpitations, and diarrhea and is found to have Graves’ disease. Before she begins therapy for her thyroid condition, she has an episode of acute chest pain and presents to the ED. Although a CT angiogram is ordered, the radiologist calls to notify the treating physician that this is potentially dangerous.

Case 13

Which of the following best explains the radiologist’s recommendation?A. Pulmonary embolism is exceedingly rare in Graves’

disease.B. Radiation exposure in patients with hyperthyroidism is

associated with increased risk of subsequent malignancy.C. Iodinated contrast exposure in patients with Graves’

disease may exacerbate hyperthyroidism.D. Tachycardia with Graves’ disease limits the image quality

of CT angiography and will not allow accurate assessment of pulmonary embolism.

E. The radiologist was mistaken; CT angiography is safe in Graves’ disease.

Case 13

Which of the following best explains the radiologist’s recommendation?A. Pulmonary embolism is exceedingly rare in Graves’ disease.B. Radiation exposure in patients with hyperthyroidism is associated with

increased risk of subsequent malignancy.C. Iodinated contrast exposure in patients with Graves’ disease may

exacerbate hyperthyroidism.D. Tachycardia with Graves’ disease limits the image quality of CT angiography

and will not allow accurate assessment of pulmonary embolism.E. The radiologist was mistaken; CT angiography is safe in Graves’ disease.

Pts with Graves’ disease produce thyroid-stimulating immunoglobulins. They subsequently produce higher levels of T4 compared with the normal population. As a result, many patients with Graves’ disease are mildly iodine deficient, and T4 production is somewhat limited by the availability of iodine. Exposure to iodinated contrast thus reverse iodine deficiency and may precipitate worsening hyperthyroidism. Additionally, the reversal of mild iodine deficiency may make I-125 therapy for Graves’ disease less successful because thyroid iodine uptake is lessened in the iodine-replete state.

Case 14

Which of the following statements best describes Graves’ ophthalmopathy?A. Although a cosmetic problem, Graves’

ophthalmopathy is rarely associated with major ocular complications.

B. Diplopia may occur from periorbital muscle swelling.

C. It is never found without concomitant hyperthyroidism.

D. The most serious complication is corneal abrasion.

E. Unilateral disease is not found.

Case 14

Which of the following statements best describes Graves’ ophthalmopathy?A. Although a cosmetic problem, Graves’ ophthalmopathy is rarely associated

with major ocular complications.B. Diplopia may occur from periorbital muscle swelling.C. It is never found without concomitant hyperthyroidism.D. The most serious complication is corneal abrasion.E. Unilateral disease is not found.

Although lid retraction can occur in any type of hyperthyroidism, Graves’ disease is associated with specific eye signs that are thought to be due to the interaction of autoantibodies within the periorbital muscles. The onset of Graves’ ophthalmopathy may occur before or after hyperthyroidism, and rarely may not be associated with hyperthyroidism at all. Proptosis occurs in 1/3 of patients and may result in corneal abrasion if there is failure of closure of the eyelids, esp during sleep. However, the most serious manifestation is compression of the optic nerve at the apex of the orbit, which can lead to papilledema and permanent vision loss if left untreated.

Case 15

23 y/o woman is evaluated for a 2 week history of nervousness, palpitations, nausea, vomiting and weight loss. She is 3 weeks pregnant and says she was previously in excellent health. The patient takes a daily prenatal multivitamin but no other prescription medication, iodine supplement or other OTC meds. On exam: BP 130/79, HR 110 and regular. Cardiac, lung, and eye exam are normal. The thyroid gland shows a significantly enlarged gland with a soft bruit but no nodules. No neck tenderness. Abdominal exam reveals a 2cm patch of vitiligo. A fine bilateral hand tremor and warm, moist skin are noted. No evidence of pretibial myxedema.

Case 15

Labs:CBC & CMP: normalTSH: < 0.01, Free T4: 4.0 (high), Free T3: 6 (high)Human chorionic gonadotropin: positiveThyroid peroxidase Ab: 40 units/L (normal is <20)Thyroid stimulating Ab: 140% (normal is <130%)

Which of the following is the most appropriate initial treatment?A. MethimazoleB. PropylthiouracilC. ThyroidectomyD. Reassurance

Case 15

Which of the following is the most appropriate initial treatment?A. MethimazoleB. PropylthiouracilC. ThyroidectomyD. Reassurance

In pregnant women, untreated hyperthyroidism is associated with an increased risk of miscarriage, fetal growth retardation, premature delivery, and preeclampsia. This patient has autoimmune Graves hyperthyroidism and should receive propylthiouracil while in the 1st trimester of pregnancy. She can switch to methimazole in the 2nd & 3rd trimesters, at which time there is decreased risk of fetal abnormalities (e.g. aplasia cutis, choanal atresia) after fetal organogenesis.

References

Agabegi SS, Agabegi ED. Step-Up to Medicine, 3rd ed. 2013. Lippincott Williams & Wilkins. Philadelphia, PA.

DeGroot, LJ. Diagnosis and Treatment of Grave’s Disease. Feb 2012. http://www.thyroidmanager.org/chapter/diagnosis-and-treatment-of-graves-disease/

Sabatine MS. Pocket medicine, 4th ed. 2011. Lippincott Williams & Wilkins. Philadelphia, PA.

Trevor AJ, Katzung BG, Kruidering-Hall M, et al. Katzung & Trever’s Pharmacology: Examination & Board Review, 10th ed. 2013. McGraw-Hill. New York, NY.

Weiner C, Fauci AS, Braunwald E, et al. Harrison’s Principles of Internal Medicine: Self-Assessment & Board Review, 17th ed & 18th ed. 2008, 2012. Lippincott Williams & Wilkins. Philadelphia, PA.

Special thanks to Dr. Sood for the inspiration!