The document discusses various thyroid cases commonly seen in clinical practice and provides guidance on thyroid examination and testing. It describes how to evaluate thyroid function test results using a "nine square" approach and discusses distinguishing postpartum thyroiditis from Graves' disease. It also addresses questions on thyroid testing in pregnancy, thyroid hormone replacement therapy and management of hypothyroidism and benign thyroid nodules.

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2. 2
Some interesting cases commonlySome interesting cases commonly
seen in practiceseen in practice
1. Govindammal – Persistant diarrhea
2. Sridhar – Cachexia 70 kg to 40 kg
3. Kavitha – Weight loss – lung shadow
4. Sulochana – Severe anaemia – CHF
5. Laxmi – Infertility after 16 yrs of ML
6. Siva – Atrial fibrillation – cachexia
7. Kadirvelu – uncontrolled diabetes
8. Annaji – dyspnea – tracheal compression

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Clinical Exam. of ThyroidClinical 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
 Pemberten”s sign for RSG

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Clinical Exam of ThyroidClinical Exam of Thyroid

5. PEMBERTEN”S SIGNPEMBERTEN”S SIGN
5
LOOK HIS FACE

6. Difficult situationsDifficult situations
6

7. 7
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
- 90% of hormone secreted is T4
- 10% of hormone secreted is T3

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Thyroid Function Tests
1. TSH
2. Free T4
3. Free T3
4. Anti-Thyroid Antibodies
5. Nuclear Scintigraphy
6. FNAC of nodule
Ultra sound is the basic test to see for thyroid nodule and goitre

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Thyroid Antibodies
Anti-TPO antibodies are commonly
associated with Hashimoto's thyroiditis and
TRAbs are commonly associated with
Graves' disease
The most clinically relevant anti-thyroid autoantibodies are
Anti-thyroid peroxidase antibodies (anti-TPO ),
&Thyrotropin receptor antibodies (TRAbs)

10. 10
What tests should I order ?
As per the Guidelines of the AACE
1. TSH alone if Hypothyroidism is suspected
2. TSH and Free T4 only if Hyperthyroidism is
suspected or for routine evaluation
3. Free T3 if T3 toxicosis is suspected
4. For follow-up of treatment only TSH
5. Don’t order for Total T4 or Total T3
6. Never order RAIU in pregnancy

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THYROID HORMONES
TEST REFERENCE RANGE
TSH Normal Range 0.3 - 4.0 mU/L
Free T4 Normal Range 0.7-2.1 ng/dL

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How toHow to
interpretinterpret
results ?results ?

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The Nine Square Game
To evaluate our Thyroid patient
As per the AACE Guidelines

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LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
LOWNORMALHIGH
FREETHYROXINEorFT4
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
EUTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
PRIMARY
HYPOTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
PRIMARY
HYPERTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
SECONDARY
HYPOTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
SECONDARY
HYPERTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
SUB-CLINICAL
HYPERTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
SUB-CLINICAL
HYPOTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
NON THYROID
ILLNESS or NTI
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
NTI or Pt.
on ELTROXIN
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

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LOWNORMALHIGH
FREETHYROXINEorFT4
EUTHYROID
SUB-CLINICAL
HYPERTHYROID
NON THYROID
ILLNESS - NTI
NTI or Pt.
on ELTROXIN
SUB-CLINICAL
HYPOTHYROID
SECONDARY
HYPERTHYROID
SECONDARY
HYPOTHYROID
PRIMARY
HYPERTHYROID
PRIMARY
HYPOTHYROID
LOW NORMAL HIGH
THYROID STIMULATING HORMONE - TSH
BASIC THYROID EVALUATION

25. CASE DISCUSSIONCASE DISCUSSION
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A 26 year old female presented to her obstetrician
with complaints of palpitations. She states the
palpitations have been constant over the past two
weeks but seem worse at nighttime.

26. CASE DISCUSSIONCASE DISCUSSION
 She recently delivered a normal baby 45days before this
visit. Her review of system is remarkable except for loose
stools occurring approximately 4 times/day. . She denies
any nausea, vomiting or abdominal pain.. She denied heat
or cold intolerance
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27. CASE DISCUSSIONCASE DISCUSSION
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Her blood pressure was 146/90. Pulse 96 and regular and
a normal temperature of 37 degrees . Her review of
systems revealed clear lungs, normal heart rhythm, normal
abdomen and she showed a fine tremor of the hands
Her thyroid was approximately 1.5 times normal in size,
symmetrically enlarged, firm, non-tender with carotids
palpable bilaterally without bruits

28. Lab investigationsLab investigations
She also had a thyroid panel that included ,
 Free T4 15.2 ng /dl
(Normal Range 0.7-2.1 ng/dL)
and a TSH of <0.05 (NL 0.3 5.0).
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Primary hyperthyroidism
DIAGNOSIS

29. CASE DISCUSSIONCASE DISCUSSION
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The patient had a radioactive iodine uptake scan
which was normal and subsequently had thyroid
auto-antibodies determined which were positive for
Anti TPO and neg for TRAbs .
Diagnosis - GRAVES DISEASE ??

30. CASE DISCUSSIONCASE DISCUSSION
 A thyroid biopsy was also performed and
revealed diffuse, lymphocytic infiltration, a
characteristic histologic picture of post partum
thyroiditis.
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31. CASE DISCUSSIONCASE DISCUSSION
31
In this case the patient was simply treated with
beta blockers to reduce the palpitations. Inside
three months, the thyroiditis had resolved and
the patients' symptoms disappeared with normal
thyroid function test results.

32. DISCUSSIONDISCUSSION
Post partum thyroiditis (PPT) is a relatively
common disorder expressed in 5 to 15% of post
partum women.
This disorder initially presents as thyrotoxicosis
from 6 weeks to 3 months post partum, is
associated with an auto immune component and
usually resolves spontaneously after 1-2 months
of expression.
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33. DISCUSSIONDISCUSSION
In some patients, the thyrotoxic phase can be
followed by a hypothyroid phase before spontaneous
disease resolution occurs. This thyroid disorder is
more prevalent in patients with a family history of
Hashimoto's thyroiditis. Over 50% of patients will
have a mild goitre
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34. DISCUSSIONDISCUSSION
The symptoms of thyrotoxicosis are generally
milder than that of Graves disease,however the
presenting symptoms can be similar and it is
important to distinguish thyrotoxicosis due to
PPT and Graves disease since the approach to
treatment is quite different between the two.
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35. DISCUSSIONDISCUSSION
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The radioactive iodine uptake or thyroid
scan can be used to differentiate Graves
disease from PPT.
A normal scan or uptake is observed in
patients with PPT in contrast to Graves
where there is a marked elevation in
radioactive iodine uptake

36. Anti TPO &TRAbsAnti TPO &TRAbs
36
Tt has been suggested that screening with TPO antibodies
in high risk pregnancy could identify those patients at risk of
developing post partum thyroiditis.
To distinguish PPT from Graves disease, measurement of
TRAbs and the use of the thyroid scan are approaches that
can help confirm the diagnosis. Both are abnormal with
Graves disease and normal in the patients with PPT.

37. HOW TO DIFFERENTIATEHOW TO DIFFERENTIATE
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Question # 1Question # 1
Should a serum TSH & F T4
be a routine component of
the health exam in
pregnant women?yes

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Question # 2Question # 2
What is the appropriate
biochemical end point for
adequate thyroid hormone
replacement in hypothyroid
patient?
 TSH starts showing decrements from the high values
 TSH returns to normal eventually

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Question # 3Question # 3
Are there risks
associated with over
replacement?

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Over-replacement risks
Reduced bone density / osteoporosis
Tachycardia, arrhythmia. atrial fibrillation
In elderly or patients with heart disease, angina,
arrhythmia, or myocardial infarction

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Question # 4Question # 4
Are all L-thyroxine
products therapeutically
equivalent? Should
combination T4/T3
preparations be used?

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 Treatment of choice is levothyroxin
 Brand consistency recommended
 No divided doses - illogical
 Not recommended for use :
Desiccated thyroid extract
Combination of thyroid hormones
T3 replacement except in Myxedema coma
Many Causes, One Treatment

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Question # 5Question # 5
What is the impact of
pregnancy on Thyroxine
replacement therapy in a
hypothyroid women?Pregnancy ( 25% ↑ in dose),

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Question # 6Question # 6
safe in lactating mother
Safety in lactating mother

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Question # 7Question # 7
Should women with sub-
clinical hypothyroidism
be treated with L-
Thyroxine?Normal FT4 & TSH elevated from 5 to <10

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Co-morbidity
Hypercholesterolemia
Depression
Infertility – Menstrual Irregularities
 Recent Wt gain
High TPO levels

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Question # 8Question # 8
Should euthyroid patient
with benign thyroid
nodules be placed on
thyroid hormone
suppression therapy?

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Thyroid hormone suppression therapy
This involves treating a benign nodule with levothyroxine .
The idea is that supplying additional thyroid hormone will
signal the pituitary to produce less TSH, the hormone that
stimulates the growth of thyroid tissue.
Although this sounds good in theory, levothyroxine therapy
is a matter of some debate. There's no clear evidence that
the treatment consistently shrinks nodules

50. SURGERYSURGERY
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Occasionally, a nodule that's clearly benign may require surgery,
especially if it's so large that it makes it hard to breathe or swallow.
Surgery is also considered for people with large multinodular goiters,
particularly when the goiters constrict airways, the esophagus or
blood vessels.
Nodules diagnosed as indeterminate or suspicious by a biopsy also
need surgical removal, so they can be examined for signs of cancer.

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The Commandments
 Highly suspect hypothyroidism
 Growth and pubertal delay
 Unexplained depression
 TSH is the test in Hypothy.
 TSH, FT4 to confirm Dx.
 Nine square magic
 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

52. Thank uThank u
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