Information Sheet for Candidates

A 60 year old patient, Mr. Shawn Green,

presents first time in your general practice. He
recently moved to Melbourne from Sydney and
is looking for a family doctor. His main
problems at present are that he does not cope
well with the cold weather here and he finds his
new job very exhausting and is quite low in his
mood about it all.
Your task is to:

take a history
examine the patient
arrange for appropriate investigations
explain your diagnosis and suggested
management to the patient

HOPC: Six months ago, Mr. Green has been transferred by his retail company from
Sydney to Melbourne to open a new store. This really came at the most inconvenient time
because he is going through major marital problems, facing a divorce. Professionally he
had been thinking of retiring in a year or two and now he finds himself in a very busy
role and stressful situation. He is not coping very well, feels rather exhausted and almost
a bit depressed.
Even though the company has provided him with a lovely apartment in the city, he finds
himself lonely, he does not engage in much physical exercise like he used to do in
Sydney. He feels he has become quite unfit and slow. His diet is rather unhealthy with a
lot of take-away or restaurant food and consequently he has gained about 10 kg in 6
months. He also suffers from constipation. In addition to all this he noticed some loss of
hair and he is developing a bold head.
In a nutshell, he does not enjoy life in Melbourne. He hates the cold weather here.
PHx. + FHx.: unremarkable
SHx: separated, going through divorce, 2 adult children, no medication, NKA, non
smoker, social drinker.
Examination: BP 135/75, P 56, RR 18, afebrile, SaO2 98 % on RA.
His neck is stocky, no goiter.
His ankle jerks are slow (delayed relaxation)
Otherwise the physical examination is normal.
MOST LIKELY DIAGNOSIS?: HYPOTHYROIDISM (Myxoedema)!!!
Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such
as a typical facies, hoarse slow speech, and dry skin and by low levels of thyroid
hormones. It is common in the elderly (women > men). The term MYOEDEMA refers to
the acculmulation of mycopolysaccharide in subcutaneous tissue.
1. IATROGENIC: radioiodine therapy or post surgery
2. MEDICATION: amiodarone, lithium
3. IDIOPATHIC or PRIMARY (autoimmune) atrophy of the thyroid
4. SECONDARY: PITUITARY / HYPOTHALAMIC LESIONS
CLASSICAL SYMPTONS AND SIGNS:
Early changes are subtle and can be misdiagnosedW
Myxoedematous face with large tongue, puffy eyes
Weight gain
Goiter
Slow and deep toned, husky voice,
Brittleness and loss of hair
Dry, cool, thickened oedematous skin
Alopecia of scalp and eyebrows
Mental apathy, drowsiness

Lethargy, lack of energy and physical slowing down

Sensitivity to cold
Constipation
Pallor
Positive Tinels sign (carpal tunnel!)

Special considerations:
In panhypopituitarism (secondary hypothyroidism) treatment with thyroxine
should only be started after adrenocortical replacement therapy because otherwise
an adrenal crisis could be triggered off!!!
Exclude ischaemic heart disease before treatment with thyroxine, which can cause
AMI!
Investigations
Hb 120 (normocytic-normochromic, can be hypochromic because of menorrhagia
or macrocytic because of associated pernicious anaemia or decreased absorption
of folate)
TSH elevated in primary hypothyroidism, normal or low in secondary
hypothyroidism!
T4 (free thyroxin) decreased!
Cholesterol elevated
ECG sinus bradycardia, low voltage, flat T waves
Management:
Treatment of underlying cause
Thyroxine 75 150 micro gram, o, daily (start with low dose!)
Monitor TSH levels (ideally between 0.5 and 2 mIU/L)