This document discusses the diagnosis and management of hypothyroidism. It outlines the typical symptoms of hypothyroidism seen on history and examination. Key diagnostic tests include thyroid function tests which show low T4 and high TSH levels in primary hypothyroidism. Treatment involves thyroid hormone replacement therapy starting at a low dose and gradually increasing to a maintenance dose of 100-150 micrograms daily. Complications of untreated hypothyroidism can include heart disease, infections, constipation, and in rare cases, myxedema coma.

1. HYPOTHYROIDISM DIAGNOSIS AND
MANAGEMENT
By: DR. MANSOOR ALI VIRK
CMC LARKANA

2. DIAGNOSIS OF HYPOTHYROIDISM

3. 1. HISTORY
  Headache
  Fatigue
  Lethargy
  Weakness
  Arthralgia
  Myalgia
  Weight gain
  Cold intolerance
  Sleep disturbance
  Absence of sweet
  Constipation
  Amenorrhea Menorrhagia

5. 2. EXAMINATION

6.  HANDS:-
  Peripheral cyanosis
  Swelling
  Dry cold skin
  Anemia
 ARMS:-
  Pulse
  carpel tunnel syndrome by tapping the flexor retinaculum medial to the
base of thenar eminent )
  Bicep reflex
  Test for proximal myopathy
 FACE-
  Alopecia
  Dry thin hair
  Priorbital edema
  General swelling
  Loss of outer halves of eye brows
  Vitiligo
  Tongue swelling
  Check for the hoarseness of voice and slowness of speech



8.  LEGS-
  Slow relaxation of ankle jerk
  Peripheral neuropathy and edema
 CHEST:-
  Pleural or pericardial effusion
  Rough sand paper like appearance over the
chest

9. INVESTIGATIONS

10. SPECIFIC INVESTIGATION
  TFT Thyroid function test
 Primary hypothyroidism
  Serum T4 
  Serum T3 not valuable
  Serum TSH   20 m/L
  Secondary hypothyroidism
  Serum T4 
  Serum TSH low or normal
 Note- Hashimotos thyroiditis increase circulating
level of anti thyroglobulin antibodies

12. NON-SPECIFIC INVESTIGATIONS
  Serum LDH and cretinine kinase 
  Serum cholesterol and triglycerides 
  Serum sodium 
  Anemia with normal or increase MCV
 ECG-
  Prolonged hypothyroidism shows sinus
bradycardia with low voltage complex ST Segment
and T WAVE abnormality.

13. DIFFERENTIAL DIAGNOSIS

14.  Anemia
  Obstructive sleep apnea
  Dementia
  vitamin D deficiency
  Adrenal insufficiency
  Lyme disease

15. TREATMENT

16.  Treatment with thyroxin replacement.
 Starts with low dose of 50 g/day for 3 weeks increasing there
after to 100 g/day for further 3 weeks.
 Finally shift maintenance dose 100-150 g/day.
 Note:- thyroxin should be taken to avoid concomitant food and
drugs that may interfere its absorption.
 Note:- thyroxin half life is 7 days so it should always be taken
as a single dose daily and at least 6 weeks pause to repeat
the TFT.
 Patient feel better within 2-3 weeks reduction in weight and
peri-orbital puffiness occur quickly but restoration of skin
texture take 3-6 months.

18. COMPLICATIONS

19.   CAD and CF due to hyperlipidemia
  Increase chance for infection
  Mega colon
  Myxedema madness:- psychosis with paranoid
delusions
  Infertility(rare)
  Pregnancy in hypothyroidism often result
miscarriage
  Myxedema coma.

20. MYXEDEMA OF FACE