Patient 1 - Oregon High School



Patient 1

A 30-year-old white female reported 1 year of fatigue, apathy, hoarseness, neck swelling, and cold intolerance. She worked as a medical receptionist and experienced increasing difficulty answering phone calls due to deepened voice quality and delayed responses to callers. Prior clinical impressions included depression, job stress, and laryngitis. Acute laryngitis is often a secondary bacterial infection triggered by infecting agents causing such illnesses as colds. There was no response to antibiotics or antidepressant medication. On examination, she was found to have a deep, gruff voice, periorbital edema, 40 gram goiter, and delayed AJRP. Cholesterol, CPK, and MCV were elevated.

Extreme TSH elevation of 417 mU/L and decreased T4 of 1.7 ug/dL confirmed the presence of severe hypothyroidism.

AMA titer of 1:1,600 suggested autoimmune thyroiditis as the etiology.

She received thyroxine 25 ug daily and prednisone 5 mg daily for 1 week, with upward titration of thyroxine every 4 weeks to a maintenance dose of 125 ug daily. Vigor returned, voice improved, and temperature tolerance normalized within 1 month. Cholesterol, CPK, MCV, and TSH normalized within 5 months. She received advanced medical training and was promoted to a nursing position in the same office.

Patient 2

A 38-year-old white male experienced 1 year of progressive fatigue, weakness, lethargy, cold intolerance, mental dullness, and erratic driving while working as a forklift operator. He was evaluated in the Family Medicine Center at the insistence of his wife who had earlier requested clomiphene, a synthetic drug that is used to stimulate ovulation for her inability to conceive a second child.

A thorough medical examination for diagnostic purposes revealed no female etiology.

The husband's fatigue and apathy were attributed to overwork. He had received radioiodine therapy for Graves disease at age 16, with erratic physician follow-up for over 20 years. On evaluation he displayed slow mentation, thick-tongued speech, periorbital edema, and delayed AJRP.

The clinical impression of postirradiation hypothyroidism was confirmed by detection of a TSH of 612 mU/L and T4 less than 1.0 ug/dL. Cholesterol and CPK were elevated. Testosterone was low at 146 ng/dL (normal: 270-1070). Semen analysis revealed extensive abnormalities in sperm anatomy and motility.

He received thyroxine 50 ug daily with prednisone 5 mg daily for 7 days. Within 6 months, energy level rebounded, eyelid edema resolved, mental acuity returned, driving improved, CPK normalized, and T4 rose to 4.9 ug/dL with TSH down to 29 mU/L, on thyroxine 150 ug daily. TSH, testosterone, and semen analysis normalized in 8 months. The couple celebrated the birth of a healthy daughter 11 months later.

Patient 3

A 24-year-old white female had 4 months of fatigue, weakness, irritability, sadness, reduced libido, profuse hair loss, and inability to lose weight, following the birth of her second child 6 months earlier. She assisted her husband with leadership of a large church youth group but found her performance compromised due to worsening fatigue and mood disturbance. She attended a physician-directed weight loss clinic without success and withdrew due to fatigue. Symptoms were attributed to postpartum depression. On initial evaluation, a 30-gram goiter and frontal hair loss were detected, along with normal mentation and AJRP.

The clinical impression of hypothyroidism was confirmed by a TSH of 384 mU/L, T4 less than 1.0 ug/mL, and T3 diminished at 49 ng/mL. Values for CPK, MCV, and cholesterol were normal. AMA titer was 1:102,400, documenting the presence of postpartum autoimmune thyroiditis.

With thyroxine 50 ug daily and upward titration, she regained strength, endurance, and emotional stability within 3 months, and lost 14 pounds with renewed capacity for aerobic exercise. TSH fell to 3 mU/L, T4 rose to 8.4 ug/mL, and AMA titer decreased to 1:25,600. All laboratory values normalized within 6 months, as did mood and functional status.

Patient 4

A 26 year old white female presented to her obstetrician with complaints of heart palpitations. She states that the palpitations have been constant over the past two weeks but seem worse at nighttime. When asked to describe them, she states that they are regular and it feels as if her heart is going to jump out of her chest. She denies chest pain, shortness of breath or lightheadedness. She has felt a bit warm of late. She recently delivered a normal baby boy during an uncomplicated delivery 5 1/2 weeks before this visit. Her review of system is remarkable for loose stools occurring approximately 4 times/day. She complains of feeling tired but unable to get a good night sleep. She states that she feels as if her mind is racing. She denies any nausea, vomiting or abdominal pain. She also denies muscle aches, fevers or chills. She denied heat or cold intolerance.

On physical examination, she presented as a thin, white female in no apparent distress. Her blood pressure was 146/90. Pulse 96 and regular and a normal temperature of 37 degrees taken orally. Her review of systems revealed clear lungs, normal heart rhythm, normal abdomen and a normal neurological response although she showed a fine tremor of the hands. Her neck was supple with no lymphadnopathy however her thyroid was approximately 1.5 times normal in size, symmetrically enlarged, firm, non-tender with carotids palpable bilaterally without bruits.

Her blood work at the time of the clinic visit included a CBC (WBC 14.2, Hct, 38.6, MCV normal, platelet count normal, differential 56% neutrophiles, 7% bands, 34% lymphocytes and 3% monocytes) and a chemistry screen that included electrolytes (NA 142, K 3.6, Cl 101, CO2 22), glucose 86, BUN 26, creatinine 1. She also had a thyroid panel that included thyroxine 16.2 (NL 4-13), T3 resin uptake 34% (NL 25 - 35%) and a TSH of ................
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