THYROID SEMINAR I Thyroid Dysfunction

and Thyroid Testing

Learning Objectives:

• Review core basic pathophysiologic mechanisms of thyroid disease

• Apply these core concepts to clinical scenarios in small group settings
• Analyze various strategies in the practical application of these concepts to clinical
scenarios

CASE #1
A 56-year-old woman complains of progressive fatigue, muscle aches, feeling cold,
and a 10-lb weight gain over the past year. On physical examination she appears
sallow and a bit puffy, her hands and skin are cool and dry, and the deep tendon
reflex relaxation is slightly slow ("hung-up") at the ankle and biceps tendons. The
thyroid gland is not palpable.
1. What laboratory tests should be ordered to confirm the clinical suspicion of
hypothyoidism?
2. A physician orders a serum T3, which is 50 (normal range 45-137 ng/dl).
Does this indicate that she is euthyroid? Why or why not? Is this test useful in
this patient?
3. What is the most likely cause of hypothyroidism in this woman? What test
might confirm this cause?

CASE #2

A 52-year-old woman complains of chronic fatigue, muscle aches, and dry skin.
She is being treated with prednisone for rheumatoid arthritis. Her physician
suspects hypothyroidism, and laboratory evaluation shows total T4 4.0 µg/ml
(normal 4.5-12.0) and TSH 1.8 (nl 0.4-4.0). Additional testing shows low thyroxine
binding globulin 10 µg/ml (normal 14-32).

1. What is the difference between thyroxine binding globulin (TBG) and

thyroglobulin?
2. How does the level of thyroxine binding globulin affect total and free thyroid
hormone levels?
3. What is the cause of the low level of thyroxine binding globulin?
4. Is the free T4 likely to be low or normal?
5. Is this hypothyroidism?
CASE #3

A 35-year-old woman complains of nervousness, 20-lb. weight loss, tremor,

sweating, and irritated bulging eyes for 5 months. The pulse is 120/min and the
thyroid is diffusely enlarged, with a bruit on auscultation.

1. What tests would confirm the suspicion of thyrotoxicosis? Could the free T4
be normal?
2. What is the most likely cause of the thyrotoxicosis in this patient? What tests
would confirm this etiology?
3. What are the treatment options for this patient? What are the disadvantages
of each?

CASE #4
A 31-year-old woman who is three months postpartum has suffered for several
weeks from palpitations, tremor, and nervousness. Pulse is 98/min, and there is a
25-gram diffuse goiter with no tenderness. Exam of the eyes is normal. Lab testing
shows elevated T4 and T3 with suppressed TSH.
1. What is the most likely cause of thyrotoxicosis here?
2. What tests would help confirm the diagnosis?