Josh Ackerman
Laura McKeague
Hypothyroidism Clinical Integration Presentation
Clinical Scenario: 35 YO Female presenting to a Family Practice office.
Chief Complaint: At the request of the patient’s mother she made an appointment. “I lost my job about
(how long?), moved back in with my parents, and now my mom is on my case because I can’t seem to
find a new job. My stomach began hurting… so here I am.”
HPI: Be prepared to answer questions from your classmates about additional negative or positive
information…
OPQRST: Patient lost her job, as a secretary at Eli Lilly, 6 months ago during a downsizing of the
company. She had been employed for 10 years with the company. She has put in a few applications
here and there but no one wants to hire a college dropout these days. Patient says she is only here
because her mother says she “has no motivation anymore.” Pain in the epigastric area x 1 week. Patient
has taken antacids but it doesn’t seem to relieve “heartburn” sensation. The pain began intermittently
but has been constant x 2 days. Pain is 8/10. Denies associated abdominal symptoms? Need more…the
students will want to know more about the abdominal pain. Denies NVD, constipation (consider being
positive) any history in past, food—better or worse…need to build this up more. Make better or
worse—anything? Exercise/activity? Anhedonia? Past surgeries? Menstrual cycles? Sexually active?
Fevers? Urinary symptoms? Diet?
Associated Symptoms:
Weight gain x 20 lbs in the last 6 months. Patient has been eating a lot of McDonald’s lately.
Fatigue.
Joint Pain. Non-descript generalized pain that patient cannot pinpoint.
Differential Diagnosis:
Hypothyroidism
Depression
What psychiatric disorders present with anhedonia?
Schizophrenia
Bipolar 2 Disorder: Hypomanic Disorder
Cyclothymic Disorder
Major Depressive Disorder with Catatonic Feature
Huntington’s Disease
B12 deficiency
Multiple Sclerosis
GERD
Pancreatitis
Cholecystis
Josh Ackerman
Laura McKeague
PMH
Unremarkable. NKDA. No childhood illness, past surgeries, or hospitalizations. Not currently taking any
medications. Takes a multivitamin, folic acid, and fish oil.
Social History:
Drinks a glass or two of wine a night. Admits to smoking marijuana occasionally since being a teenager.
Denies use of any other drugs or use of cigarettes.
Family History:
Both parents living. Grandmother died at age 83 and grandfather died at age 70 from a heart attack.
Father has high blood pressure, high cholesterol, and is overweight. Patient feels animosity towards
mother and says she has always been “dramatic” and takes a handful of medication on a daily basis.
Patient does not know what medications mother has been on but admits she has always struggled with
weight issues.
ROS
Skin:
In cold weather, patient’s fingers turn white. More of an annoyance than a complaint for the patient.
Skin is dry – patient equates dryness to the winter season.
HEENT:
Constant headache x 1 year. Headache waxes and wanes, with no temporal association. Patient takes
Ibuprofen for management of headache. No changes in vision, aura, prodrome, scotoma, flashing lights
associated with headache. No complaints associated with ears, eyes, nose, or throat. Patient has not
noticed any swollen glands or enlarged lymph nodes.
Breasts:
Patient has no new symptoms or complaints. Patient does not do self breast exams.
Respiratory:
Patient has no new symptoms or complaints.
Cardiovascular:
Patient has no new symptoms or complaints.
Musculoskelatal:
Decreased strength. Patient does not exercise regularly and does not have a gage for exercise tolerance.
Joint stiffness and pain x 1 year. (HPI)
Josh Ackerman
Laura McKeague
GI:
Bowel Habits are “normal” according to the patient. If defined normal is one bowel movement every
three days. Bowel movements have had no change for years. No melena, hematochezia. Patient denies
anorexia, or changes to eating habits other than craving McDonald’s more. Patient believes nutrition is
well rounded – eats meat, vegetables, fruit, etc. what does she think is behind weight gain?
Stomach pain – burning quality located in the epigastrium, worsens with intake of McDonald’s. Radiates
to the back. This is part of HPI…patient complaining of stomach pain in CC.
Genital/Reproductive:
Age of menarche: 13 years old. Last menstruation 4 weeks prior to office visit. Last few menstrual cycles
seemed heavier than normal and lasted 8 days. Denies sexual activity due to decreased libido. (HPI)
Psychiatric:
Patient doesn’t feel “depressed” but admits that she doesn’t find joy in many things. Denies suicidal
ideation. Patient rather sit at home watching TV than doing much of anything. (HPI)
Physical Exam:
Patient appears fatigued and in acute distress leaning forward in her chair with a dull, aloof facial
expression. Patient has lethargic movements and is slow to answer your questions. In answering
questions you note that her voice appears to have a hoarse quality.
HEENT: Other than puffy eyes rest of exam is unremarkable.
Skin: Dry appearance with brittle/broken nails.
Musculoskeletal: Delayed deep tendon reflexes.
Are you doing any other differential diagnoses after physical exam?
Lab Values:
Beck’s Depression Scaleresults?
CBC
Josh Ackerman
Laura McKeague
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Hct 32% (Normal 45%)
Hgb 11.5 g/dL (Normal 12.5 g/dL)
MCV 90 (Normal 90)
MCHC 34 (Normal 30)
Electrolytes
 Na 130 (Normal 135-145) Does this need worked up ?
o (Hyponatremia is a common finding in hypothyroid)
 Cl 100 (Normal 96-106)
 K 4.2 (Normal 3.4-5.2)
 Ca 9.1 (Normal 8.5-10.2)
 HC03 20 (Normal 20-29)
 BUN 10 (Normal 7-20)
 Cr 1.0 (Normal 0.6-1.2)
 Glucose 100 (Normal 74-106)
 All other values are normal
Metabolic Panel
 HDL 35 (Normal >60)
 LDL 140 (Normal <100)
 Triglycerides 300 (Normal <150)
 Total Cholesterol 265 (Normal <200)
Pancreatic Enzymes
 Amylase 200 (Normal 150
 Lipase 200 (Normal 150)
Thyroid autoantibodies: This reveals an autoimmune thyroiditis (Hashimoto)
 Thyroid peroxidase (TPOAb) - positive
 Thyroglobulin (TgAB) – positive
 TSH-Receptor Antibodies (TRAb) – negative
o Also positive in Grave’s Disease –Hyperthyroidism
Normal Thyroid Function Tests
 TSH 4 ( Normal 0.4-2 microunits/mL)
 Total T4 3,200 (Normal 4,500-11,200 ng/dL)
Josh Ackerman
Laura McKeague
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Total T3 72 (Normal 100-200ng/dL)
Free T4 700 (Normal 900-2,400 ng/dL)
Free T3 0.180 (Normal 0.230-0.420 ng/dL)
TR3U (Normal 24-37%)
Radioactive Iodine Uptake scan: Also reveals Hashimoto pattern.
 Cannot do in pregnant or nursing women. Get a pregnancy test first!
Diagnosis list?
Differential Diagnosis for Hypothyroidism:
Primary Hypothyroidism (decreased T3/T4, increased TSH)
Hashimoto’s Throiditis  Autoimmune
Congenital  Cretinism
Iodine Deficiency
Medications
Infiltrating Diseases  Sarcoid, Cancer
Secondary Hypothyroidism (decreased T3/T4, decreased TSH)
Pituitary, Hypothalamic Dysfunction
Hypothalamic – Anterior Pituitary-Thyroid Axis
TRH  TSH  T3/T4 negative feedback to hypothalamus
Treatment and Patient Educational
Will need to give thyroid hormone to patient such as Synthroid. What dose? How do you know when
to recheck? How often, etc. When do you give synthroid? Instructions?
Josh Ackerman
Laura McKeague
Educate patient on lifestyle changes. Diet: eliminate fast-food and fatty foods. Eat more fruit,
vegetables, and fiber. Exercise and weight loss is important. Start a statin to reduce cholesterol to
decrease triglyceride levels then initiate thyroid hormone treatment. With pancreatic involvement,
want to eliminate alcohol intake as well. Are you saying to start thyroid treatment after triglyceride
levels normalized? Nope…(just in case…)
Abdominal pain treatment or????
Social aspects of job loss?
Starting a statin can be expensive for someone without a job—no insurance? What to do? Are you
worried about using a statin with possible pancreatitis issues?????? Better change?