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Case Study: Primary hypothyroidism
 
 
A 56 year-old woman patient presents with a history of deafness, poor mobility and occasional falls. She appears slow to respond and although her appetite remained unchanged, she has started to put on weight. The patient also reported feeling very sleepy most of the time and that she was constipated. She had no history of coughing, chest pain or palpitations and no urinary problems
 
 

Clinical Examination:
Obese
Pale and confused
Thinning hair and puffy lower eyelids
Dry skin
Pulse: 62 beats/min, regular
Blood pressure 150/90 mmHg (prone), 140/78mmHg (standing)
No thyroid or lymph node enlargement
Apex beat not easily palpable
In sinus rhythm with no murmur
Resp/Adbo exam normal
Sluggish tendon reflexes & loss of sense of vibration
Simple mental function test score = 6/10

Test results:
 

Haemoglobin:
10.9g/dL
(macrocytic, normochromic)
 
Bicarbonate:
24 mmol/L

WBC:
7.4 x 109/L
P:78% L:19%
M:2% E:1%
 
Chloride:
102mmol/L

MCV:
95fl
 
Blood Urea:
10.8mmol/L  (64.8mg/L)

ESR:
38mm in 1st hour
 
Creatinine:
138mmol/L
(1.5mg/dL)

Sodium:
134mmol/L
 
Blood glucose:
7.1mmol/L
128mg/dL

Potassium:
4mmol/L
 
Urine:
Protein+, sugar nil, bacteria +++

 
ECG:
Normal sinus rhythm

 

 
Q1. Differential diagnoses?
Q2. Diagnosis?
 
Q3. Neuropsychiatric features of this disease?
 
Q4. What further investigations would you do in the lab to look for indicators of disease?
 
Q5. What are these likely to indicate?
 
Q6. What would you expect to happen to the primary markers in each of these Thyroid disorders?

 
Total T4
Total T3
fT4
fT3
TBG
TSH

Euthyroid
 
 
 
 
 
 

Hyperthyroid
 
 
 
 
 
 

T3 toxicosis
 
 
 
 
 
 

Hypothyroid
 
 
 
 
 
 

TBG Excess
 
 
 
 
 
 

TBG Deficiency
 
 
 
 
 
 

T4 displacement by drug
 
 
 
 
 
 

 
Q7.Patients Results:

 
Normal
Patient

fT4
12-25pmol/L
5.7pmol/L

TSH
0.2-5mU/L
54.6mU/L

 
Q8: Definitive diagnosis and treatment?

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