slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Knowledge is essential Applied, it is Wisdom Wisdom is Happiness PowerPoint Presentation
Download Presentation
Knowledge is essential Applied, it is Wisdom Wisdom is Happiness

Loading in 2 Seconds...

play fullscreen
1 / 113

Knowledge is essential Applied, it is Wisdom Wisdom is Happiness - PowerPoint PPT Presentation


  • 152 Views
  • Uploaded on

Knowledge is essential Applied, it is Wisdom Wisdom is Happiness. Abnormal Thyroid Function A Practical Approach. Clinical Exam. of Thyroid. Have patient seated on a stool / chair Inspect neck – also while drinking water Examine with neck in relaxed position

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Knowledge is essential Applied, it is Wisdom Wisdom is Happiness' - willow


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Knowledge is essential

Applied, it is Wisdom

Wisdom is Happiness

www.drsarma.in

slide2

Abnormal

Thyroid Function

A Practical Approach

clinical exam of thyroid
Clinical Exam. of Thyroid
  • Have patient seated on a stool / chair
  • Inspect neck – also while drinking water
  • Examine with neck in relaxed position
  • Palpate from behind the patient
  • Remember the rule of finger tips
  • Use the tips of fingers for palpation
  • Palpate firmly down to trachea
  • Pemberton’s sign for RSG
slide9

Thyroid Gland

Hormonogenesis

thyroid regulation

HYPOTHALAMUS - TRH

ANT. PITUITARY - TSH

THYROID T4 and T3

PLASMA T4 + FT4

PLASMA T3 + FT3

TISSUES FT4 to FT3, rT3

Thyroid Regulation

TSH -R

in the thyroid gland
In the Thyroid Gland

There the following 5 steps in the hormonogenesis

  • Trapping of inorganic Iodine from dietary Iodides
  • Activation of Iodine to high valance I2
  • Incorporation of I2 into Tyrosine of Thyroid Globulin
  • Coupling of formed MIT and DIT to form T4 & T3
  • Proteolysis of Thyroglobulin to release T4 & T3
metabolism of thyroid hormones
Metabolism of Thyroid Hormones

Thyroid Gland

100 nm

Thyroxine FT4

5 nm

< 5 nm

45 nm

35 nm

Reverse T3 (rT3)

Triiodothyronine (FT3)

20 nm

Tertrac etc.,

what happens in fluorosis

Normal catabolism -Thyroxine

FT4 FT3

rT3 will be LOW

rT3 ÷ T3 ratio will be LOW

Normal deiodination of T4

Abnormal catabolism -Thyroxine

FT4 FT3

rT3 will be HIGH

rT3 ÷ T3 ratio will be HIGH

Fluoride affects the normal

deiodination of T4

rT3

rT3

What happens in Fluorosis
the thyronines
The Thyronines

Mono Iodo Tyrosine – MIT

Di Iodo Tyrosine – DIT

Tri Iodo Thyronine – T3 –half life 6 hours

Tetra Iodo Thyronine – T4 half life 7 days

Reverse T3 - metabolically inactive

T4 is 99.9% protein bound to TBG, TPA, TA

T3 is 99.5% protein bound to TBG, TPA, TA

Bound hormones are inactive – should not be measured

Only Free T4 and Free T3 are metabolically active

slide15

The Thyroxines

Tri Iodo Thyronine – T3

- 10% is from thyroid gland

- 90% derived from conversion of T4 to T3

Tetra Iodo Thyronine – T4

- Is exclusively from thyroid gland

From the thyroid gland

- 80% of hormone secreted is T4

- 20% of hormone secreted is T3

thyroid function tests
Thyroid Function Tests
  • TSH
  • Free T4
  • Free T3
  • Anti-Thyroid Antibodies
  • Nuclear Scintigraphy
  • FNAC of nodule
what tests should i order
What tests should I order ?
  • As per the Guidelines of the AACE and ATA, ITS
  • 1. TSH alone if Hypothyroidism is suspected
  • 2. TSH and Free T4only if Hyperthyroidism is suspected or for routine evaluation
  • 3. Free T3 if T3 toxicosis is suspected
  • 4. For follow-up of treatment only TSH
  • Don’t order for Total T4 or Total T3
  • Never order RIU in pregnancy or lactation
which lab to choose
Which Lab to choose ?
  • Depends on the method of estimation of hormones
  • EquilibriumDialysis is the gold Standard for TSH
  • Radio-immuno assay - 3rd or 4th gen. RIA is the best
  • Reliability of ELISA is not adequate
  • Chemiluminescence immuno assay - CIA is the gold standard for FT4 but expensive and less widely available

Choose a lab which offers 3rd or 4th generation RIA method

the nine square game
The Nine Square Game

To evaluate our Thyroid patient

As per the AACE and ITS Guidelines

slide22

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide23

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide24

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

PRIMARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide25

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide26

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

SECONDARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide27

BASIC THYROID EVALUATION

SECONDARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide28

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide29

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide30

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

NON THYROID

ILLNESS or NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide31

BASIC THYROID EVALUATION

NTI or Pt.

on ELTROXIN

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide32

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

NTI or Pt.

on ELTROXIN

SECONDARY

HYPERTHYROID

SUB-CLINICAL

HYPERTHYROID

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

SECONDARY

HYPOTHYROID

PRIMARY

HYPOTHYROID

NON THYROID

ILLNESS - NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide33

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide34

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

PRIMARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide35

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide36

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

SECONDARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide37

BASIC THYROID EVALUATION

SECONDARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide38

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide39

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide40

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

NON THYROID

ILLNESS or NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide41

BASIC THYROID EVALUATION

NTI or Pt.

on ELTROXIN

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

slide42

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

NTI or Pt.

on ELTROXIN

SECONDARY

HYPERTHYROID

SUB-CLINICAL

HYPERTHYROID

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

SECONDARY

HYPOTHYROID

PRIMARY

HYPOTHYROID

NON THYROID

ILLNESS - NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

thyroid hormones
THYROID HORMONES

TSH upper limit will soon be revised to 2.5 mU/L

t f t in progressive hypothyroidism
T.F.T. in Progressive Hypothyroidism

TSH

Mild

Moderate

Severe

Normal Range

Free T3

Free T4

nucleotide scintigraphy
Nucleotide Scintigraphy
  • I 123 and TC 99m Radio Nucleotide Scintigraphy
  • This test is not at all required in hypothyroidism
  • This is only to confirm a hyper functioning thyroid or
  • To assess whether a nodule is ‘hot’ or ‘cold’
  • Never order for this test for hypothyroidism
  • Similar is the case with FNAC – in hypothyroid goiter
  • If TSH is high and FT4 is low there is no role for FNAC
thyroid antibodies
Thyroid Antibodies
  • Anti Microsomal (TM ) Antibodies
  • Anti Thyroglobulin (TG) Antibodies
  • Anti Thyroxine Per Oxidase (TPO) Ab.
  • Anti Thyroxine antibodies
  • Thyroid Stimulating (TSA) Antibodies
  • High titres TPO Ab in Hashimotos & Reidle’s thyroiditis
  • Anti thyroxine Ab in peripheral resistance to Thyroxine
  • TSA (TSI) in Graves’ Hyperthyroidism
hypothyroidism
Hypothyroidism
  • Epidemiology
    • Most common endocrine disease
    • Females > Males – 8 : 1
  • Presentation
    • Often unsuspected and grossly under diagnosed
    • 90 % of the cases are Primary Hypothyroidism
    • Menstrual irregularities, miscarriages, growth retard.
    • Vague pains, anaemia, lethargy, gain in weight
    • In clear cut cases - typical signs and symptoms
    • Low free T4 and High TSH
    • Easily treatable with oral Levo-thyroxine
classification of hypothyroidism
Classification of Hypothyroidism

A. Primary

1. Enlarged Thyroid

- Hashimoto’s (65%)

- Iodine Deficiency (25%)

- Drug-induced (Lithium)

- Dysharmonogenesis

2. Normal Thyroid

- Spontaneous Atrophic

Primary contd..

3. Post Ablative

- Permanent

- Transient

- Sub-clinical

4. Congenital

B. Secondary / Central

Pituitary/ hypothalamic

slide54

Disease Burden

5% of the general population are Sub-clinically Hypothyroid

15 % of all women > 65 yrs. are hypothyroid

Detecting sub-clinical hypothyroidism in pregnancy is highly essential – order for TSH and FT4 routinely in all pregnant women at the beginning of each trimester

All persons aged above 60 years – Order for TSH

slide55

Multi system effects - Hypothyroidism

  • Neuromuscular
  • Aches and pains
  • Muscle stiffness
  • Carpel tunnel syndrome
  • Deafness, Hoarseness
  • Cerebellar ataxia
  • Delayed DTR, Myotonia
  • Depression, Psychosis
  • Gastro-intestinal
  • Constipation, Ileus, Ascites
  • Dermatological
  • Dry flaky skin and hair
  • Myxoedema, Malar flushes
  • Vitiligo, Carotenimia, Alopecia
  • General
  • Lethargy, Somnalence
  • Weight gain, Goitre
  • Cold Intolerence
  • Cardiovascular
  • Bradycardia, Angina
  • CHF, Pericardial Effusion
  • HyperlipIdemia, Xanthelsma
  • Haematological
  • Iron def. Anaemia,
  • Normo cytic /chromic Anaemia
  • Reproductive system
  • Infertility, Menorrhagia
  • Impotence, Inc. Prolactin
slide56

Clinical Signs of Hypothyroidism

  • Coarse Hair; Dry cool and pale skin
  • Goitre (not in all cases), Hoarseness of voice
  • Non-pitting oedema (myxoedema)
  • Puffiness of eyes and face
  • Delayed relaxation of DTR
  • Slow hoarse speech and slow movements
  • Thinning of lateral 1/3 of eye brows
  • Bradycardia, pericardial effusion
what the mind knows the eyes see
What the mind knows the eyes see !!

Order for TSH alone as a screen

  • Psychiatric patients
  • Elderly women / men
  • Hypercholesterolemia
  • Lithium, Amiodarone
  • Postpartum women
  • Other Autoimmune disease
  • Rx. Grave’s Ophthalmopathy
  • Family H/o thyroid disease
  • Neck irradiation therapy
  • Previous Rx for thyrotoxicosis
  • Autoimmune Thyroiditis
thyroid failure organ systems
Thyroid Failure - Organ Systems

Cardiovascular

  • Decreased ventricular contractility
  • Increased diastolic blood pressure
  • Decreased heart rate

Central Nervous

  • Decreased concentration
  • General lack of interest
  • Depression

Gastro-instestinal

  • Decreased GI motility
  • Constipation
slide59

Thyroid Failure - Organ Systems

  • Musculoskeletal
  • Muscle stiffness, cramps, pain, weakness, myalgia
  • Slow muscle-stretch reflexes, muscle enlargement, atrophy

Renal

  • Fluid retention and oedema
  • Decreased glomerular filtration
slide60

Thyroid Failure - Organ Systems

Reproductive

  • Arrest of pubertal development
  • Reduced growth velocity
  • Menorrhagia, Amenorrhea
  • Anovulation, Infertility

Hepatic

  • Increased LDL / TC
  • Elevated LDL + triglycerides
slide61

Thyroid Failure - Organ Systems

Skin and Hair

  • Thickening and dryness of skin
  • Dry, coarse hair, Alopecia
  • Loss of scalp hair and / or lateral eyebrow hair
xanthomata
Xanthomata

Tuberous Xanthoma

Xanthelasma

slide71

Solid Oedema

Xanthomata

slide75

26.7.98

Clearing of Pericardial Effusion with Rx.

slide76

14.9.99

Reappearance of Pericardial Effusion

after treatment is discontinued

co morbidity
Co-morbidity
  • Hypercholosterolemia
  • Depression
  • Infertility – Menstrual Irregularities
  • Diabetes mellitus
hypothyroidism and hypercholesterolemia
Hypothyroidism and Hypercholesterolemia
  • 14% of patients with elevated cholesterol have hypothyroidism
  • Approximately 90% of patients with overt hypothyroidism have increased cholesterol and / or triglycerides
lipids in patient with hypothyroidism
Lipids in Patient with Hypothyroidism

Hypercholesterolemia(>200 mg/dL)

Hypertriglyceridemia(>150 mg/dL)

Hypercholesterolemia and mild Hyper TG

Normal Lipids

N= 268

ldl c levels increase with increasing hypothyroidism grade
LDL-C Levels Increase With Increasing Hypothyroidism Grade

246

191

168

144

137

133

LDL-C(mg/dL

C

1

2

3

4*

5†

Hypothyroidism Grade

Basal TSH (mU/L) 1.1 3.0 8.6 22.7 44.4 63.7

effect of thyroxine therapy on hypercholesterolemia in patients with mild thyroid failure
Effect of Thyroxine therapy on Hypercholesterolemia in Patients with mild Thyroid failure

“The decrease in total cholesterol achieved with [Thyroxine replacement] substitution therapy in patients with subclinical hypothyroidism [mild thyroid failure] may be considered as an important decrease in cardiovascular risk favouring treatment.”

hypothyroidism and depression
Hypothyroidism and Depression
  • Depressive symptoms are common in hypothyroidism
  • Many hypothyroid patients fulfill DSM-IV criteria for a depressive disorder
  • Depressed patients may be more likely than normal individuals to be hypothyroid
  • All depressed patients should be evaluated for thyroid dysfunction
hypothyroidism and depression1
Hypothyroidism and Depression

Hypothyroidism

Depression

Constipation

Decreased Conc.

Decreased libido

Depressed mood

Diminished interest

Weight increase

Fatigue

Bradycardia

Cardiac and lipid Abnormalities

Cold intolerance

Hair and skin changes

Delayed reflexes

Goiter

Sleep decreaseSuicidal ideation Weight change Delusions

thyroxine in depression
Thyroxine in Depression

1. Thyroxine therapy is recommended for

patients with depression who have

persistently elevated serum TSH

2. Antidepressants may be less effective if

thyroid function not normalized

hypothyroidism and infertility
Hypothyroidism and Infertility

1. Hypothyroidism associated with infertility,

miscarriage, stillbirth

2. Infertility : Evaluate thyroid function, treat

hypothyroidism

3. Equivocal results: Begin therapy; discontinue

if no pregnancy for several months.

suspect hypothyroidism
Suspect Hypothyroidism
  • Amenorrhea
  • Oligomenorrhea
  • Menorrhogia
  • Galactorrhea
  • Premature ovarian failure
  • Infertility
  • Decreased libido
  • Precocious / delayed puberty
  • Chronic urticaria
hypothyroidism and diabetes
Hypothyroidism and Diabetes
  • Approximately 10% of patients with type 1 diabetes mellitus develop sub-clinical hypothyroidism
  • In diabetic patients - examine for goitre
  • TSH measurement at regular intervals
slide88

Algorithm for

Hypothyroidism

slide89

Algorithm for Hypothyroidism

Measure TSH

Elevated TSH

Normal TSH

Measure FT4

Considering Pituitary

Normal

Low

No

Yes

No tests

Sub-clinical hypo

Primary hypothyroid

Measure FT4

TPO -

TPO -

TPO +

TPO +

Low

Normal

Hashimoto

Evaluate Pituitary

Sick Euthyroid

Drugs effect

T4 repl

Annual FU

No tests

Others

many causes one treatment
Many Causes, One Treatment
  • Goal : Normalize TSH level regardless of cause of hypothyroidism
  • Treatment : Once daily dosing with Levothyroxine sodium (1.6µg/kg/day) this comes to 100 mcg per day
  • Monitor TSH levels at 6 to 8 weeks, after initiation of therapy or dosage change
slide92

Many Causes, One Treatment

  • Treatment of choice is levothyroxin
  • Branded thyroxine recommended
  • Brand consistency recommended
  • No divided doses - illogical
  • Not recommended for use :
    • Desiccated thyroid extract
    • Combination of thyroid hormones
    • T3 replacement except in Myxedema coma
slide93

Dosage Adjustments

  • Age (in elderly start with half dose)
  • Severity and duration of hypothyroidism (↑ dose)
  • Weight (0.5µg/kg/day ↑ upto 3.0µg/kg/day)
  • Malabsorption (requires ↑ dose)
  • Concomitant drug therapy (only on empty stomach)
  • Pregnancy ( 25% ↑ in dose), safe in lactating mother
  • Presence of cardiac disease (start alt. day Rx)
slide94

Start Low and Go Slow

  • Goal : normalize TSH level – 25, 50 and 100 mcg tablets avail.
  • Starting dose for healthy patients< 50 years at 1.0 µg/kg/day
  • Starting dose for healthy patients > 50 years should be < 50 µg/day. Dose ↑ by 25 µg, if needed, at 6 to 8 weeks intervals.
  • Starting dose for patients with heart disease should be 12.5 to 25 µg/day and increase by 12.5 to 25 µg/day, if needed, at 6 to 8 weeks intervals
slide95

How the patient improves

  • Feels better in 2 – 3 weeks
  • Reduction in weight is the first improvement
  • Facial puffiness then starts coming down
  • Skin changes, hair changes take long time to regress
  • TSH starts showing decrements from the high values
  • TSH returns to normal eventually
slide96

Drug Interactions

  • Malabsorption Syndromes
  • Reduced Absorption
    • Cholestyramine resin
    • Sucralfate
    • Ferrous sulfate
    • Soybean formula
    • Aluminum hydroxide
    • Colestipol hydrochloride
  • Drugs that affect metabolism
    • Rifampin
    • Carbamazepine
    • Phenytoin
    • Phenobarbitol
    • Amiodarone
slide97

Inappropriate Dosage

Over-replacement risks

  • Reduced bone density / osteoporosis
  • Tachycardia, arrhythmia. atrial fibrillation
  • In elderly or patients with heart disease, angina,

arrhythmia, or myocardial infarction2

Under-replacement risks

  • Continued hypothyroid state
  • Long-term end-organ effects of hypothyroidism
  • Increased risk of hyperlipidemia
diet in iodine deficiency
Diet in Iodine deficiency
  • Iodized salt
  • Selenium supplementation
  • Avoid Cassava
  • Avoid cabbage (goitrogens)
  • Avoid formula milk
  • Fish, meat, milk & eggs
sub clinical hypothyroidism
Sub-clinical Hypothyroidism
  • Chronic autoimmune thyroiditis
  • Graves’ hyperthyroidism with radioiodine, surgery
  • Inadequate replacement therapy for hypothyroidism
  • Lithium carbonate therapy (for depressive illness)
post partum thyroiditis ppt
Post-Partum Thyroiditis (PPT)

Definition

  • Occurrence of hyperthyroidism and / or hypothyroidism during the postpartum period in women who were euthryroid during pregnancy

At Highest Risk

  • Patients with type 1 diabetes, previous history of PPT or other autoimmune disease such as Hashimoto’s disease and Graves’ disease
myxedema coma
Myxedema Coma
  • Precipitating factors :
    • Infection, trauma, stroke, cardiovascular, hemorrhage drug overdose, diuretics
  • Signs and Symptoms :
    • Mental confusion, hypothermia, bradycardia, older age,
    • ↓Na, ↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑CPK
    • ↓ EKG voltage, myxedema, b-carotnenemia
  • Treatment
    • ICU transfer, T3 100 µg IV sixth hourly, 500 µg of T4 , antibiotics, ventilation, hydrocortisone IV, passive warming, careful volume management
slide103

Sick Euthyroid Syndrome

  • Total T3 reduced
  • FT3 reduced
  • Total T4 reduced
  • FT4 Normal
  • TSH Normal
  • Clinically Euthyroid
slide105

The Commandments

  • All obese patients TSH a must
  • For all pregnant -test TSH, FT4
  • Postmenopausal 15% Hypothy
  • Start low and go slow
  • Use Levothyroxine only
  • Always on empty stomach
  • Thyroxine - avoid empirical use
  • Highly suspect hypothyroidism
  • Growth and pubertal delay
  • Unexplained depression
  • TSH is the test in Hypothy.
  • TSH, FT4 to confirm Dx.
  • Nine square magic
  • Test cord blood for TSH
question 1
Question # 1

Should a serum TSH be a routine component of the periodic health exam in women?

question 2
Question # 2

What is the appropriate biochemical end point for adequate thyroid hormone replacement in hypothyroid patient?

question 3
Question # 3

Are there risks associated with over replacement?

question 4
Question # 4

Are all L-thyroxine products therapeutically equivalent? Should combination T4/T3 preparations be used?

question 5
Question # 5

What is the impact of pregnancy on Thyroxine replacement therapy in a hypothyroid women?

question 6
Question # 6

What is the impact of breast feeding on the management of maternal hypo and hyperthyroidism?

question 7
Question # 7

Should women with sub-clinical hypothyroidism be treated with L-Thyroxine?

question 8
Question # 8

Should euthyroid patient with benign thyroid nodules be placed on thyroid hormone suppression therapy?