Question

Melina is a 36-year-old female with complaints of excessive fatigue, muscle aches, difficulty sleeping, weight gain, and hair loss in the past six months. She recently lost her job as a clerk and is under a lot of stress. She denies taking any medication and denies any medical history. She is crying at the clinic today and tells you that she does not feel right. Her labs demonstrate that her TSH is significantly elevated at 8. How will you approach and manage her complaints? What discussion will you have with the patient regarding her therapy going forward

Answer 1

This patient is most likely suffering from hypothyroidism

Clues to the diagnosis:

History:

• Fatigue
• Muscle aches
• Difficulty sleeping ( due to increase night time apnea. This occurs due to soft tissue deposition around the upper airways)
• Weight gain
• Hair loss
• Crying ( hypothyroidism is associated with depression)

Lab test

• Thyroid stimulating hormone is elevated.
  • Hypothyroidism is characterized by low level of thyroxine hormone.
  • The secretion of thyroxine hormone is under negative feedback control.
  • When the thyroxine levels are high, the TSH level is low or reduced.
  • When the thyroxine levels are low, the TSH levels are high ( as in t his case)

Approach to a case of hypothyroidism:

1. There are 3 types of hypothyroidism
   1. Primary hypothyroidism - the defect is in the thyroid gland, This includes
      1. Autoimmune thyroiditis
      2. Drug induced
      3. Iatrogenic
      4. Post partum thyroiditis
   2. Secondary hypothyroidism - the defect is in the pituatary gland
   3. Tertiary hypothyroidism - the defect is in the hypothalamus

The following test need to be performed in assess a case of hypothyroidism:

1. Thyroid function test - this includes thyroid stimulating hormone, T3 and T4
   1. The test can be interpreted in the following ways:

      • T3 levels	Low	Low
        T4 levels	Low	Low
        TSH levels	Low	High
        	Central hypothyroidism ( secondary and tertiary hypothyroidism)	Primary hypothyroidism

   2. Anti-thyroid peroxidase levels and anti-thyroglobulin level to look for evidence of autoimmunity
   3. Ultrasonography of the thyroid gland - to look for evidence of thyroid swelling, solitary nodule or diffuse inflammatory activity
   4. Fine needle aspiration cytology for thyroid nodules
   5. Histopathology of thyroid biopsy - in case of autoimmune cases of hypothyroidism or malignancy
2. Treatment:
   1. The patients with hypothyroidism need to be treated with thyroxine hormone.
   2. Regular exercise
   3. Specific diet restriction

The discussion that needs to be had with the patient suffering from hypothyroidism is:

1. The treatment is life long
2. The thyroxine pill has to be taken empty stomach (30 mins to 1 hour before breakfast)
3. Take the dose that is prescribe by the doctor
4. Swallow capsules who don't chew or crush them
5. It is important to get your thyroid functions repreated after thyroxine is started. This will help to adjust the dose
6. Inform the doctor if your are taking any other medicine along with thyroxine. This is to prevent drug or drug interaction.
7. Food stuff like soya, cabbage, turnips, raddish, dry fruits, soft drinks, red wine should be avoided.