A female patient aged 48 years old reports to the outpatient clinic that she suffers from persistent fatigue. She says that the problem has persisted for several months. She further says that she also feels depressed and has concentration difficulties. She is further investigated and reveals that she has been constipating over the past couple of months. She reports that she has noticed an increase in her body weight although she has experienced a loss of appetite. The woman says that she has developed brittle hair and her skin has become significantly dry. The lady who is a housewife and lives with her husband and two children does not have any medical history worth noting.
The initial physical exam shows the normal important signs, has no swelling in the face, her tongue is normal, her skin moist enough, her eyebrows aren’t thinned out, the eyelids have not thickened either, does not exhibit perorbital swelling, no neck thickening has no unusual cardiovascular activity, no unusual pulsations and no goiter either.
Review of Systems
The review of the system showed non-contributory, with physical exam outcome showing typical trends. It incorporated the vital pulse rate signs, pressure of blood and blood mass index and signals of hypothyroidism such as enlarged thyroid gland, ankle jerk relaxation period delayed, dry skin, hypothyroid face, frontal hair recession, myopathy, effusions and cerebellar signs (El-Shafie, 2003).
Objective
DIAGNOSIS
Hypothyroidism
Hypothyroidism is primarily caused by thyroid function failure and insufficient thyroid stimulating hormone release from the pituitary gland or TRH released from the hypothalamus. It is possible to differentiate secondary hypothyroidism in hypothalamic and pituitary by use of the TRH test. In some instances, the failure of the action of the hormone in the tissues on the periphery can be observed. Hypothyroidism at primary level can be clinical where T4 is reduced and TSH increased in turn. It may also be subclinical where in which TSH is increased while FT4 in normal.
FT4 is reduced in secondary hypothyroidism while TSH in reduced or normal (Athanassiou & Ntalles, 2010). The most common cause of primary hypothyroidism is chronic autoimmune thyroiditis. Radioiodine treatment and thyroidectomy are some of the less common causes. Iodination of salt, routinely done in many countries, could increase the occurrence of overt hypothyroidism. The occurrence of clinical hypothyroidism is 0.5 -1.9 % among women and less than 1% in men. The subclinical figures are 3 to 13% among women and 0.75% in men (Athanassiou & Ntalles, 2010). It is important to distinguish between subclinical hypothyroidism and clinical hypothyroidism. Clinical signs are more pronounced and serious. Some patients may even slip into a coma. Subclinical symptoms are much less and less severe (Athanassiou & Ntalles, 2010).
Assessment
Pathophysiology
Hypothyroidim is an endocrine disorder condition that can be treated easily using thyroid replacement therapy. The dosrder has been noted to persist in some patients despite having been subjected to levothyroxine. In such a setting, it is of importance that the possibility of gastrointestinal malabsorption, pancreatic disease, nephrotic syndrome, heart disease, liver disease, absorption interference of other drugs or pregnancy (Wilder, Bravenboar, Herremans, Vanderbruggen, & Velkeniers, 2017). T3 and T4 are secreted from the thyroid gland. While T4 is exclusively produced in the thyroid glands, T3 is secreted from the deiodination in extrathyroidal T4 tissue. The deficiency of T3 is responsible for the biochemical and clinical showing of hypothyroidism. Consequently, a basic function such as the consumption of oxygen by the mitochondria and the calorigenesis is delayed. The reduction in the metabolism of energy and the production of heat is manifest in the low rate of basal metabolism, reduced appetite and, intolerance to cold and a marginally lower basal temperature level of the body (Athanassiou & Ntalles, 2010).
Differential Diagnosis
Chronic fatigue syndrome
CFS, which is the shorthand for chronic fatigue syndrome, is a common health condition that constitutes physical and mental fatigue. It is usually diagnosed after excluding medical.....
Athanassiou, K., & Ntalles, K. (2010). Hypothyroidism - new aspects of an old disease. Hippokratia, 82–87.
El-Shafie, K. T. (2003). CLINICAL PRESENTATION OF HYPOTHYROIDISM. J Family Community Med., 55–58.
Keller, J., & Layer, P. (2014). The Pathophysiology of Malabsorption. Viszeralmedizin., 150–154.
Kezunovic, L. C., & Cojic, M. (2017). Subclinical Hypothyroidism – Whether and When To Start Treatment? Open Access Maced J Med Sci., 1042–1046.
Wilder, N., Bravenboar, B., Herremans, S., Vanderbruggen, N., & Velkeniers, B. (2017). Pseudomalabsorption of Levothyroxine: A Challenge for the Endocrinologist in the Treatment of Hypothyroidism. Eur Thyroid J., 52–56.
