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Medical Case Study Culminating Assignment

batool towailib

on 18 April 2015

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 symptoms of hypothyroidism
Resident presentation
Past History
Clinical presentation
Myxedema coma

Results in patients with hypothyroidism are as follows:

Elevated TSH with decreased T4 or FTI
Elevated TSH with normal free T4 or FTI is considered mild or subclinical hypothyroidism:
Dilutional hyponatremia
Reversible increases in creatinine 
Elevations in transaminases and creatinine kinase

Patients with a history of neck irradiation
Monotherapy with levothyroxine (LT4) remains the treatment of choice for hypothyroidism.
in young and healthy patients can be started on LT4 at anticipated full replacement doses
In elderly patients and those with known ischemic heart disease, begin with one fourth to one half the expected dose and adjust the dose in small increments after no less than 4-6 weeks
For most cases of mild to moderate hypothyroidism, a starting LT4 dose of 50-75 µg daily will suffice
Clinical benefits begin in 3-5 days and level off after 4-6 weeks
Achieving a TSH level within the reference range may take several months
LT4 dosing changes should be made every 6-8 weeks until the patient’s TSH is in target range

Thanks for Attention !
Special thanks to Dr. Alya Alhjaj
Dr. Weeam AL Hubail
internal medicine

Case Report
An 87-year-old man with multiple chronic medical problems was seen in an outpatient clinic because of sore throat and fatigue

The patient had been in his usual health until several weeks before presentation, when hoarseness, sore throat, and increasing fatigue developed.

At the urging of his family, he was seen by his physician in an outpatient clinic . He reported hoarseness, increasing facial puffiness, and periorbital swelling, with no chest pain, dyspnea, or new joint pains or muscle aches

with a normal thyrotropin level 8 months earlier
gastroesophageal reflux disease
abdominal aortic aneurysm
chronic back pain
depression related to the death of his wife several years before
recurrent urinary tract infections.

Two months earlier, the creatinine level was 2.22 mg per deciliter which was stable, as compared with values obtained the previous year.
The patient had
chronic kidney disease.
In the past, he had had

undergone angioplasty of the right renal artery (10 years earlier)

wrist surgery.

a cholecystectomy

photoselective vaporization of the prostate due to obstructive benign prostatic hypertrophy (2 months before this presentation)
The patient was retired and lived alone. He could independently perform activities of daily living, and he managed his own medications.

His three children lived nearby and were in frequent contact with him, but he came to most medical appointments unaccompanied.

He was under the regular care of an internist, a nephrologist, a cardiologist, and a urologist.

Immunizations were up to date.

He had stopped smoking many years earlier and did not drink alcohol.

His father had died of liver cancer, and a son had sarcoidosis; his two other children were healthy

On Examination
the patient was pleasant, smiling, and in no distress; he spoke with a hoarse voice.

BP 130/72 mm Hg

pulse 59 beats per minute

oxygen saturation 96% R.A

the weight 86.8 kg (approximately 4.5 kg greater than it had been 1 month earlier) and the BMI 29.9

There was facial swelling and periorbital edema

the remainder of the examination was normal.

Blood levels of glucose
Total protein
Total bilirubin
Plasma anion gap

An appointment with an otolaryngologist was scheduled

the patient returned home.

Two days later, when the results of the laboratory tests were known, he was instructed by his physician to stop taking atorvastatin, and a follow-up appointment was scheduled for 9 days later in the outpatient clinic for repeat blood tests

Seven days after presentation, the patient called his doctor’s office at his daughter’s urging to report persistent hoarseness and swelling of his face and abdomen, which he indicated had been present for months but had, according to his daughter, worsened recently.

Four days later,days after presentation, he was seen in the outpatient clinic, where he reported markedly

worsening fatigue, especially after walking, with associated dyspnea
facial edema
weight gain
cough that produced white mucus

He reported no chest pain or worsening arthralgias and stated that he was taking all his medications.

complete blood count
white-cell differential count
blood levels of glucose
total protein
total bilirubin
C-reactive protein

Differential Diagnosis
Final Diagnosis
Severe hypothyroidism.

Hypothyroidism is a common endocrine disorder resulting from deficiency of thyroid hormone. In areas of adequate iodine intake, autoimmune thyroid disease (Hashimoto disease) is the most common cause of hypothyroidism

worldwide, iodine deficiency remains the foremost cause.

Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic. Symptoms and signs are often subtle and neither sensitive nor specific

Fatigue, loss of energy, lethargy
Weight gain
Decreased appetite
Cold intolerance
Dry skin
Hair loss
Muscle pain, joint pain, weakness in the extremities
Emotional lability, mental impairment

Forgetfulness, impaired memory, inability to concentrate
Menstrual disturbances, impaired fertility
Decreased perspiration
Paresthesia and nerve entrapment syndromes
Blurred vision
Decreased hearing
Fullness in the throat, hoarseness
symptoms more specific to Hashimoto thyroiditis:

Feeling of fullness in the throat
Painless thyroid enlargement
Transient neck pain, sore throat, or both

Weight gain
Slowed speech and movements
Dry skin
Coarse, brittle, straw-like hair
Loss of scalp hair, axillary hair, pubic hair, or a combination
Dull facial expression
Coarse facial features
Periorbital puffiness

Physical signs of hypothyroidism include the following:
Goiter (simple or nodular)
Decreased systolic blood pressure and increased diastolic blood pressure
Pericardial effusion
Abdominal distention, ascites (uncommon)
Hypothermia (only in severe hypothyroid states)
Nonpitting edema (myxedema)
Pitting edema of lower extremities
Hyporeflexia with delayed relaxation, ataxia, or both

Severe form of hypothyroidism that most commonly occurs in individuals with undiagnosed or untreated hypothyroidism who are subjected to an external stress.

Features are as follows:

Altered mental status
Cardiomegaly, pericardial effusion, cardiogenic shock, and ascites may be present

thyroid-stimulating hormone (TSH) assays are generally the most sensitive screening tool for primary hypothyroidism.
If TSH levels are above the reference range, the next step is to measure free thyroxine (T4) or the free thyroxine index (FTI), which serves as a surrogate of the free hormone level. Routine measurement of triiodothyronine (T3) is not recommended.
The American Thyroid Association recommends screening at age 35 years and every 5 years thereafter, with closer attention to patients who are at high risk, such as the following :
Reference ranges of serum TSH levels are higher in older populations (eg, >65 years), so higher serum TSH targets may be appropriate

After dose stabilization, patients can be monitored with annual clinical evaluations and TSH monitoring.

Patients should be monitored for symptoms and signs of overtreatment, which include the following:
Atrial fibrillation
Increased excitability
Possible angina

In patients who continue to have symptoms (eg, weight gain, fatigue) despite normalization of their TSH level, consideration should be given to causes other than hypothyroidism.

Initiation or discontinuation of estrogen and androgens should be followed by reassessment of serum TSH at steady state, since such medications may alter levothyroxine requirement.

When deciding on a starting dose of levothyroxine, the patient’s weight, lean body mass, pregnancy status, etiology of hypothyroidism, degree of TSH elevation, age, and general clinical context, including the presence of cardiac disease, should be considered. The serum TSH goal appropriate for the clinical situation should also be considered.

updated guidelines on hypothyroidism issued by the American Thyroid Association in 2014 maintain the recommendation of levothyroxine as the preparation of choice for hypothyroidism, with the following considerations:

If levothyroxine dose requirements are much higher than expected, consider evaluating for gastrointestinal disorders such as Helicobacter pylori –related gastritis, atrophic gastritis, or celiac disease; if such disorders are detected and effectively treated, re-evaluation of thyroid function and levothyroxine dosage is recommended.

Serum TSH should be reassessed upon initiation of agents such as tyrosine kinase inhibitors that affect thyroxine metabolism and thyroxine or triiodothyronine deiodination

Serum TSH monitoring is advisable when medications such as phenobarbital, phenytoin, carbamazepine, rifampin, and sertraline are started.

Thyroid hormone therapy should be initiated as an initial full replacement or as partial replacement with gradual increments in the dose titrated upward using serum TSH as the goal

Dose adjustments should be made upon significant changes in body weight, with aging, and with pregnancy; TSH assessment should be performed 4-6 weeks after any dosage change.

Recommendations concerning hypothyroidism treatment in pregnant women are as follows:
Pregnant women with overt hypothyroidism should receive levothyroxine replacement therapy with the dose titrated to achieve a TSH concentration within the trimester-specific reference range.
Serial serum TSH levels should be assessed every 4 weeks during the first half of pregnancy to adjust levothyroxine dosing to maintain TSH within the trimester-specific range.
Serum TSH should be reassessed during the second half of pregnancy.
In women already taking levothyroxine, 2 additional doses per week of the current levothyroxine dose, given as one extra dose twice weekly with several days’ separation, may be started as soon as pregnancy is confirmed.

Reference ranges of serum TSH levels are higher in older populations (eg, >65 years), so higher serum TSH targets may be appropriate

Treatment of myxedema coma is as follows:
Intravenous (IV) LT4 at a dose of 4 µg/kg of lean body weight, or approximately 200-250 µg, as a bolus in a single or divided dose, depending on the patient’s risk of cardiac disease
After 24 hours, 100 µg LT4 IV, then 50 µg/day IV
Stress doses of IV glucocorticoids
Subsequent adjustment of the LT4 dose can be based on clinical and laboratory findings


a lumpectomy of the right middle lobe due to a spiculated nodule that was found to be benign
Pregnant women
Women older than 60 years
Patients with type 1 diabetes or other autoimmune disease
Inflammatory Myopathy
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