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Old 09-20-2012
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Arrow Gyrus Daily Questions; Internal Medicine #8

A patient presents to his primary care physician complaining of fatigue and hair loss. He has gained 6.4 kg since his last clinic visit 6 months ago but notes markedly decreased appetite. On review of systems, he reports that he is not sleeping well and feels cold all the time. He is still able to enjoy his hobbies and spending time with his family, and does not believe that he is depressed. His examination reveals diffuse alopecia and slowed deep tendon reflex relaxation. Hypothyroidism is high on the differential for this patient. Which of the statements regarding that diagnosis is correct?

A. A normal thyroid-stimulating hormone (TSH) excludes secondary, but not primary hypothyroidism.
B. T3 measurement is not indicated to make the diagnosis.
C. The T3/T4 ratio is important for determining response to therapy.
D. Thyroid peroxidase antibodies distinguish between primary and secondary hypothyroidism.
E. Unbound T4 is a better screening test than TSH for subclinical hypothyroidism
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Old 09-20-2012
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Is it D. Thyroid peroxidase antibodies distinguish between primary and secondary hypothyroidism.??

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Not know the answer but (a) and (e) is obviously wrong. (d) antiperoxidase is associated with Hashimoto's T< may be correct answer> (b) TSH and free T4 is use for diagnosis of HypoT and T3 use in combination with TSH and T4 not alone. (c) hypothyroidism treated with life long thyroxine T4 which converted to active form T3.

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I think B........
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The answer is B. T3 measurement is not indicated to make the diagnosis.


While hypothyroidism may be strongly suspected from history and physical examination findings, it is definitively diagnosed with serum laboratory measurements. TSH should be the first test sent. A normal TSH level excludes primary, but not secondary, hypothyroidism. Primary hypothyroidism refers to disease caused by hypofunction of the thyroid gland itself. Secondary hypothyroidism typically arises from disease of the anterior pituitary. If the TSH is low or normal and pituitary disease is suspected, a free T4 should be sent. If this test is low, the differential includes anterior pituitary dysfunction, sick euthyroid syndrome, and drug effects. TSH, not unbound T4, is the test of choice for diagnosing subclinical hypothyroidism. In these cases, TSH is elevated and T4 is normal. Thyroid peroxidase antibodies are present in >90% of patients with autoimmune hypothyroidism; this test helps distinguish autoimmune causes of hypothyroidism from other possibilities. Circulating
T3 levels are normal in ~25% of patients with clinical hypothyroidism and are not indicated for diagnosis. A T3/T4 ratio is not helpful for diagnosis or prognosis.

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