Case Study 022

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You have completed Case Study 022. Your score is %%PERCENTAGE%%. %%RATING%%

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Question 1

Mrs. Green is a 47-year-old woman who presents with neck swelling for 2 months. She had noticed a recent onset of generalized muscle aching, fatigue, hair loss, weight gain, constipation, facial edema, dry skin, and loss of the outer part of her eyebrows. She has no history of any chronic disease. She was advised by her family to see the doctor for medical advice.

On examination:

Height: 170 cm, Weight: 75.7 Kg, BMI: 26.1
BP: 132/84 mmHg, Heart Rate: 58/min, Respiratory rate: 18/min, Temperature: 36.8⁰C, O2SAT: 98%
Pale coarse dry skin, puffy eye lids, diffusely enlarged non tender neck mass. Bilateral 1+ edema on the lower extremities.

Which is the most likely affected organ in Mrs. Green?

A	Parathyroid gland
B	Thyroid gland
C	Adrenal gland
D	Heart
E	Kidney

Question 1 Explanation:

Based on the clinical symptoms and signs Mrs. Green presents with, the most likely affected organ is the thyroid gland.

Question 2

What is the initial recommended test to evaluate the thyroid function?

A	TSH
B	Free T4
C	Thyroglobulin
D	Thyroid gland ultrasound

Question 2 Explanation:

Plasma TSH level is a sensitive screening test to detect thyroid disease. Free T4 hormone level is better indicator than the total hormone level, however in some cases, free T3 or T4 can be normal even in thyroid dysfunction. Thyroglobulin is mainly used as a tumor marker for patients who have thyroid cancer. Thyroid gland ultrasound is great to identify nodules, cysts and tumours in the thyroid gland, however, does not tell a lot about its function. The required test should be reflective of the hormone production.

Question 3

Mrs. Green’s laboratory tests showed:

Blood analysis:
- CBC:
  - Hemoglobin: 125 g/L, Hematocrit: 0.37,
  - RBCs: 3.8 x 10¹²/L, MCV: 81 fL, MCH: 28 pg, RDW: 11.9 %, Reticulocytes: 1.1 %, ESR: 10 mm/hour
  - WBC: 9 X 10⁹/L, (Neutrophils: 6.3 x 10⁹/L with hyper-segmented nuclei, Lymphocytes: 3.6 x 10⁹/L, Basophils: 0.04 x 10⁹/L, Eosinophils: 0.32 x 10⁹/L, Monocytes: 0.43 x 10⁹/L)
  - Platelet count: 206 x 10⁹/L
- Na: 139 mmol/L, K: 3.9 mmol/L, Cl: 104 mmol/L, Glucose: 4.3 mmol/L, Creatinine: 77.2 umol/L, Uric acid: 298 mmol/L
- Triglycerides: 3.3 mmol/L, Cholesterol: 6.8 mmol/L, HDL: 0.7 mmol/L, LDL: 4.2 mmol/L, TC/HDL-C: 9.7
- Bilirubin: 21 mmol/L, Albumin: 41.7 g/L, AST: 32 U/L, ALT: 34 U/L
- TSH: 11 uU/mL, Total T₄: 35 nmol /L, Free T₄: 4 pmol/L, Total T₃: 0.83 nmol/L, Free T₃: 2.5 pmol/L
- Anti-thyroid peroxidase and anti-thyroglobulin antibody: negative

Urinalysis: color: yellow, specific gravity: 1017, osmolarity: 432 mmol/kg, pH: 6, glucose, ketones, nitrates, albumin, bilirubin: negative, WBCs and RBCs: 4 and 3/HPF, squamous epithelial cells: 1-2/HPF, casts, crystals, bacteria, yeast: negative.

Which of these lab tests can help in the evaluation of the patient’s condition? (select all that apply)

A	Serum creatinine
B	Neutrophil morphology
C	Free T4
D	Serum bilirubin
E	Antithyroglobulin antibody
F	Serum cholesterol
G	Urine ketone
H	Platelet count

Question 4

Have another look at Mrs. Green's thyroid function test results:

- TSH: 11 uU/mL, Total T₄: 35 nmol /L, Free T₄: 4 pmol/L, Total T₃: 0.83 nmol/L, Free T₃: 2.5 pmol/L
- Anti-thyroid peroxidase and anti-thyroglobulin antibody: negative

What is the most likely diagnosis of the patient’s thyroid disorder?

A	Primary hyperthyroidism
B	Primary hypothyroidism
C	Secondary hyperthyroidism
D	Primary hyperthyroidism

Question 4 Explanation:

In primary hypothyroidism, the TSH level is higher than normal since the pituitary gland is trying to compensate for the low T3 and T4 levels. In primary hyperthyroidism we would expect the TSH to be significantly lower than the normal range. Although it is expected in secondary hypothyroidism to see low T3 and T4 levels, the TSH would have been also lower than the normal because the pituitary gland does not produce enough TSH in such cases. In secondary hyperthyroidism, the thyroid gland over functions because of the abnormally high TSH levels from the pituitary gland. In that case, both T3 and T4 levels would be elevated.

Question 5

What of the following symptoms are the expected in hypothyroidism? (select all that apply)

A	Weight gain
B	Fatigue
C	Irritability and anxiety
D	Constipation
E	Heat intolerance

Question 5 Explanation:

Most of the signs and symptoms of hypothyroidism result from the slower metabolic processes in the body. Manifestations of hypothyroidism include weight gain, constipation, sleepiness, depression, and cold intolerance while heat tolerance and irritability are associated with hyperthyroidism. Easy fatigability can happen in both conditions.

Question 6

If a TRH stimulation test were performed to Mrs. Green before starting her treatment, what would be the expected result?

A	Baseline TSH > 10 uIU/mL, 30 minutes after stimulation > 20 uIU/mL.
B	Baseline TSH < 10 uIU/mL, 30 minutes after stimulation > 20 uIU/mL.
C	Baseline TSH > 10 uIU/mL, 30 minutes after stimulation < 20 uIU/mL.
D	Baseline TSH < 10 uIU/mL, 30 minutes after stimulation < 20 uIU/mL.

Question 6 Explanation:

TRH stimulation test is used in border-line conditions, to differentiate primary and secondary hypothyroidism. In primary hypothyroidism, there is increased level of TSH and after TRH stimulation a further increase in the TSH level could be observed. In secondary hypothyroidism however, the pituitary gland is unable to produce TSH even in the presence of TRH.

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