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Prof. Tariq Waseem
Dr. Hina Latif
Prof. Tariq Waseem
Progress
A” Wireless” pole alongside
an abandoned British Era
railway track
Pind Dadan Khan
Salt Range Punjab Pakistan
A 32 year old female executive in a multinational
organization started having low mood, lethargy
and lack of initiative and drive. She had been
receiving excellent performance awards for three
consecutive years but was not even considered for
regular annual promotion this year. She got
frustrated over this neglect and started using anti-
depressants on advice of her GP. She was
repeatedly found somnolent in her office and the
pile of files in need of her comments swelled up on
her desk. Her boss arranged a psychiatrist
consultation.
laboratory screening was ordered and a medical
consultation was advised.
Prof. Tariq Waseem
 A lady with depressed mood who is slow to
respond to questions reports being lethargic,
somnolent and feels that winters are becoming
increasingly cold over past three years. Her
appetite has reduced, she feels constipated and
her periods have been unusually heavy for past 9
months. Her hemoglobin was low so she started
taking iron supplements on advice of her GP. She
also c/o pain and numbness in lateral half of her
hands particularly when she rise up from her
desk placing them on table for support.
Prof. Tariq Waseem
A lady with cold, rough and coarse skin. She
has a slightly hoarse and croaky voice. A mild
diffuse goitre was noted.
Pulse: 56 beats/min
BP 150/95
Non pitting edema feet
Hypoaesthesia over lateral 3 fingers of both
hands and delayed relaxation of ankle jerks
was noted.
Prof. Tariq Waseem
 Hb 11.5 g/dl , MCV 104
 CPK 550 ng/l
 Serum Cholestrol 230mg/dl
 ALT 55 iu/L
 TSH > 100 ng/L
Prof. Tariq Waseem
Prof. Tariq Waseem
Chest X-Ray
Prof. Tariq Waseem
Prof. Tariq Waseem
The most common endocrine disease
Yet Grossly under diagnosed
Females > Males – 8 : 1
90 % patients have Primary Hypothyroidism
Menstrual irregularities, miscarriages,
growth retard. Vague pains, anemia,
constipation, lethargy, cold intolerance,
gain in weight, carpel tunnel syndrome are
frequent complaints.
Prof. Tariq Waseem
How Common is Hypothyroidism?
1. 5% of the general population are Sub-
clinically Hypothyroid
2. 15 % of all women > 65 yrs are hypothyroid
3. 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
4. All persons aged above 60 years – Order
for TSH
Prof. Tariq Waseem
 Hypothyroidism is common in people of every
age.
 It is most frequent in elderly
 Most common in females
 1 in every 10 people have a thyroid disorder
 1 in every 5000 infant has hypothyroid
disorder
Prof. Tariq Waseem
 IODINE DEFICENCY is the most common
cause of hypothyroidism worldwide.
 In Iodine sufficient areas, Autoimmune
disease (HASHIMOTO’S THYROIDITIS) is most
common.
Prof. Tariq Waseem
With Goiter
Hashimoto’s Thyroiditis
I2 deficiency goiter
Drug induced goiter
(Li, Amiodarone, PAS,
ethionamide, Rifampicin)
Due to goitrogens
Riedel’s thyroiditis
Without Goiter
 Hashimoto’s Thyroiditis
 Post ablative(radioactive I 2)
 After thyroidectomy
 Congenital hypothyroidism
 Secondary hypothyroidism
(Sheehan syndrome)
Prof. Tariq Waseem
 Autoimmune
hypothyroidism
(Hashimoto’s, atrophic
thyroiditis)
 Iatrogenic
(I123treatment,
thyroidectomy,
external irradiation of
the neck)
 Drugs: iodine excess,
lithium, antithyroid
drugs, etc
 Iodine deficiency
 Infiltrative disorders of
the thyroid:
amyloidosis,
sarcoidosis,haemochro
matosis, scleroderma
Prof. Tariq Waseem
 Primary
◦ Thyroid dysfunction…
 Secondary
◦ Hypopituitarism
 Tertiary
◦ Hypothalamic dysfunction
Others
Post partum
Drugs
Prof. Tariq Waseem
 Fatigue
 Weight Gain
 Depression
 Dry skin
 Bradycardia
 Constipation
 Intolerant to cold
Prof. Tariq Waseem
 Dry skin, cool extremities
 Puffy face, hands and feet
 Delayed tendon reflex
relaxation
 Carpal tunnel syndrome
 Bradycardia
 Diffuse alopecia
 Serous cavity effusions
Prof. Tariq Waseem
Symptoms
Dry & coarse skin- 76%
Cold intolerance – 64%
Puffiness of face- 60%
Sweating- 54%
Wt gain-54%
Paresthesia - 52 %
Constipation- 50%
Aches & pains non specific
Signs
Ankle reflex delayed
relaxation- 77%
Bradycardia - 58%
Somnolence
Diastolic hypertension
Depression
Anemia
Menorrhagia
 Infertility
Prof. Tariq Waseem
Hoarseness of voice
Deafness
Ascites
Pericardial & pleural effusion
Carpel tunnel syndrome
Impotence
Galactorrhoea & Amenorrhoea
Cardiac failure
Psychosis
Prof. Tariq Waseem
HYPOTHYRODISM
Prof. Tariq Waseem
Prof. Tariq Waseem
 Depression
 Dementia
 Parkinsonism
 Proximal Myopathies
Prof. Tariq Waseem
 Hypercholesterolemia
 Infertility – Menstrual
Irregularities
 Diabetes mellitus
Prof. Tariq Waseem
Primary Test
TSH
Additional Test
Free T4
Prof. Tariq Waseem
TSH raised (>3.5-5.5 according to the lab)
Free T4 decreased
Total T4 decreased
Prof. Tariq Waseem
 TSH , free T4 , free T3 ,
 Ultrasound of thyroid – little value
 Thyroid scintigraphy – little value
 Anti thyroid antibodies – anti-TPO
Prof. Tariq Waseem
 CPK ,
 AST
 LDH
 Cholestrol ,
 Triglycerides 
 Anemia:
Normochromic normocytic/macrocytic /
microcytic
 Increased serum prolactin
 Hyponatremia
Prof. Tariq Waseem
Sinus Bradycardia
Low voltage
Prolongation of the PR interval
Bundle branch blocks
Flattening or inversion of the T wave
Ventricular premature contractions (VPS)
Sustained or non-sustained attacks of ventricular
tachycardia (VT)
Prolongation of the QT interval
Prof. Tariq Waseem
Primary hypothyroidism
Transient
Recovery from NTIS
Pituitary adenoma
Primary adrenal insufficiency
T4 resistance
TSH resistance at receptor level
Prof. Tariq Waseem
Central hypothyroidism
Imaging indicated to distinguish
hypothalamic from pituitary disease
Evaluate for 2dary adrenal insufficiency
Prof. Tariq Waseem
 Improvement of symptoms
 Normalization of TSH
 Reduction of goiter
 Avoid over supplementation :
 risk of A-fib in elderly
 risk of bone loss
Prof. Tariq Waseem
Algorithm for Hypothyroidism
Measure TSH
Elevated TSH Normal TSH
Measure FT4 Considering Pituitary
Normal Low No Yes
Sub-clinical hypo
TPO + TPO -
T4 repl Annual FU
Primary hypothyroid
TPO + TPO -
No tests Measure FT4
Low Normal
No tests
Evaluate Pituitary
Sick Euthyroid
Drugs effect
Hashimoto
Others
Prof. Tariq Waseem
 Adverse Effects
◦ Angina in patients having occult IHD
◦ Osteopenia
 Contraindicated
◦ Acute MI
◦ Treatment of obesity
◦ Uncontrolled HTN
Prof. Tariq Waseem
 Goal : Normalize TSH level regardless of
cause of hypothyroidism
 Treatment : Once daily dosing with
Levothyroxine sodium (1.6µg/kg/day-
1.8ug/kg/day)
 Monitor TSH levels at 6 to 8 weeks, after
initiation of therapy or dosage change
Prof. Tariq Waseem
 Dose of Levothyroxine depends on the degree
of Hypothyroidism, Age & General health
condition of the patient
 Usually daily replacement dose is 1.6µgm/Kg
body weight
 Start with Low Dose
Prof. Tariq Waseem
 Levothyroxine
◦ If no residual thyroid function 1.5
μg/kg/day
◦ Patients under age 60, without cardiac
disease can be started on 50 – 100 μg/day.
Dose adjusted according to TSH levels
◦ In elderly especially those with CAD the
starting dose should be much less (12.5 –
25 μg/day)
Prof. Tariq Waseem
 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% -50%↑ in dose), safe in
lactating mother
 Presence of cardiac disease (start alt. day Rx)
Dosage Adjustments
Prof. Tariq Waseem
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
 Decrease in cholesterol level
Prof. Tariq Waseem
Serum TSH levels should be measured after
6-8 weeks of therapy and dosages should be
adjusted accordingly
Target TSH levels should be between 1-2
mU/l
Once a stable TSH is achieved, it should be
estimated every year
Prof. Tariq Waseem
 Obtain baseline FT4, TSH, LFT, CBCs before
initiation of therapy
 Repeat FT4 and TSH after 4-6 weeks on
therapy and 4-6 weeks after adjustments
 Once euthyroid state obtain thyroid function
test after 3-6 months
Prof. Tariq Waseem
During pregnancy requirement of thyroxin
increases by 25-50µg/d during pregnancy
Even on mild Thyroxin hormone deficiency
there are chances of low IQ and
developmental delay of the child
Hypothyroid And pregnancy
Prof. Tariq Waseem
Thyroid Hormone exists in two forms :
Free (Active) & Bound (with thyroxine
binding globuline).
In Pregnancy increased Estrogen, increases
TBG which in turn increases Total T4 & T3
level
However Free T4, Free T4 REMAINS
NORMAL.
SO Free T4 should be used in the treatment
and follow up during pregnancy & not total
T4
Prof. Tariq Waseem
 Same for the non-pregnant pt
 Goal is to normalize TSH
 Adjust dose at 4 week intervals
 Should check TSH levels every trimester in pts
with hypothyroidism
Prof. Tariq Waseem
Prof. Tariq Waseem
Prof. Tariq Waseem
 Occurs in previously:
undiagnosed hypothyroidism
inadequately treated hypothyroidism
elderly patients more susceptible
MEDICAL EMERGENCY
Prof. Tariq Waseem
 Infection/sepsis
 Drugs…(sedatives, antidepressants, anesthetic
drugs)
 Cardiac failure/ MI
 Respiratory failure/ pneumonia
 CVA
 GI bleed
 Hypoglycemia
 Dilutional hyponatremia
 Hypoxia/ hypercapnia
Prof. Tariq Waseem
Signs and Symptoms :
 Hypothermia
 Coma
 Seizures
 Other features of hypothyroidism
 Usually older age
 Bradycardia, ↓ Na,↓ glucose, ↑ CO2, ↓ WBC, ↓
Hct, ↑ CPK
 ↓ EKG voltage
Prof. Tariq Waseem
 Treatment
ICU transfer,
IV levothyroxine 500 µg bolus followed by
50-100µg/d (same dose can be given
through NG tube),
antibiotics, ventilation, hydrocortisone IV,
passive warming, careful volume
management,
correction of hypoglycemia and
hyponatremia
Prof. Tariq Waseem
When being crazy is not in your head BUT IN
THYROID
Delirium With Auditory Hallucinations &
Paranoid Delusions
Takes The Form Of Psychotic Depression Or
Pure Psychosis.
No Cognitive Impairment
Treatment- Thyroxine
Prof. Tariq Waseem
Sick Euthyroid Syndrome
 Total T3 reduced
 FT3 reduced
 Total T4 reduced
 FT4 Normal
 TSH Normal
 Clinically Euthyroid
Prof. Tariq Waseem
 Women > 60
 women with a family history of thyroid
disease,
 prior thyroid dysfunction,
 symptoms suggestive of hyperthyroidism or
hypothyroidism, abnormal thyroid gland on
examination,
 type 1 diabetes
 personal history of autoimmune disorder
Prof. Tariq Waseem
Prof. Tariq Waseem
Abandoned British Era
Railway Track
Pind Dadan Khan
Salt Range Punjab Pakistan
Mudat se koyi ayaa naa gaya
Wiran paree hai Ghar Ki Fiza

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Thyroid disorders 4

  • 2. Prof. Tariq Waseem Progress A” Wireless” pole alongside an abandoned British Era railway track Pind Dadan Khan Salt Range Punjab Pakistan
  • 3. A 32 year old female executive in a multinational organization started having low mood, lethargy and lack of initiative and drive. She had been receiving excellent performance awards for three consecutive years but was not even considered for regular annual promotion this year. She got frustrated over this neglect and started using anti- depressants on advice of her GP. She was repeatedly found somnolent in her office and the pile of files in need of her comments swelled up on her desk. Her boss arranged a psychiatrist consultation. laboratory screening was ordered and a medical consultation was advised. Prof. Tariq Waseem
  • 4.  A lady with depressed mood who is slow to respond to questions reports being lethargic, somnolent and feels that winters are becoming increasingly cold over past three years. Her appetite has reduced, she feels constipated and her periods have been unusually heavy for past 9 months. Her hemoglobin was low so she started taking iron supplements on advice of her GP. She also c/o pain and numbness in lateral half of her hands particularly when she rise up from her desk placing them on table for support. Prof. Tariq Waseem
  • 5. A lady with cold, rough and coarse skin. She has a slightly hoarse and croaky voice. A mild diffuse goitre was noted. Pulse: 56 beats/min BP 150/95 Non pitting edema feet Hypoaesthesia over lateral 3 fingers of both hands and delayed relaxation of ankle jerks was noted. Prof. Tariq Waseem
  • 6.  Hb 11.5 g/dl , MCV 104  CPK 550 ng/l  Serum Cholestrol 230mg/dl  ALT 55 iu/L  TSH > 100 ng/L Prof. Tariq Waseem
  • 10. The most common endocrine disease Yet Grossly under diagnosed Females > Males – 8 : 1 90 % patients have Primary Hypothyroidism Menstrual irregularities, miscarriages, growth retard. Vague pains, anemia, constipation, lethargy, cold intolerance, gain in weight, carpel tunnel syndrome are frequent complaints. Prof. Tariq Waseem
  • 11. How Common is Hypothyroidism? 1. 5% of the general population are Sub- clinically Hypothyroid 2. 15 % of all women > 65 yrs are hypothyroid 3. 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 4. All persons aged above 60 years – Order for TSH Prof. Tariq Waseem
  • 12.  Hypothyroidism is common in people of every age.  It is most frequent in elderly  Most common in females  1 in every 10 people have a thyroid disorder  1 in every 5000 infant has hypothyroid disorder Prof. Tariq Waseem
  • 13.  IODINE DEFICENCY is the most common cause of hypothyroidism worldwide.  In Iodine sufficient areas, Autoimmune disease (HASHIMOTO’S THYROIDITIS) is most common. Prof. Tariq Waseem
  • 14. With Goiter Hashimoto’s Thyroiditis I2 deficiency goiter Drug induced goiter (Li, Amiodarone, PAS, ethionamide, Rifampicin) Due to goitrogens Riedel’s thyroiditis Without Goiter  Hashimoto’s Thyroiditis  Post ablative(radioactive I 2)  After thyroidectomy  Congenital hypothyroidism  Secondary hypothyroidism (Sheehan syndrome) Prof. Tariq Waseem
  • 15.  Autoimmune hypothyroidism (Hashimoto’s, atrophic thyroiditis)  Iatrogenic (I123treatment, thyroidectomy, external irradiation of the neck)  Drugs: iodine excess, lithium, antithyroid drugs, etc  Iodine deficiency  Infiltrative disorders of the thyroid: amyloidosis, sarcoidosis,haemochro matosis, scleroderma Prof. Tariq Waseem
  • 16.  Primary ◦ Thyroid dysfunction…  Secondary ◦ Hypopituitarism  Tertiary ◦ Hypothalamic dysfunction Others Post partum Drugs Prof. Tariq Waseem
  • 17.  Fatigue  Weight Gain  Depression  Dry skin  Bradycardia  Constipation  Intolerant to cold Prof. Tariq Waseem
  • 18.  Dry skin, cool extremities  Puffy face, hands and feet  Delayed tendon reflex relaxation  Carpal tunnel syndrome  Bradycardia  Diffuse alopecia  Serous cavity effusions Prof. Tariq Waseem
  • 19. Symptoms Dry & coarse skin- 76% Cold intolerance – 64% Puffiness of face- 60% Sweating- 54% Wt gain-54% Paresthesia - 52 % Constipation- 50% Aches & pains non specific Signs Ankle reflex delayed relaxation- 77% Bradycardia - 58% Somnolence Diastolic hypertension Depression Anemia Menorrhagia  Infertility Prof. Tariq Waseem
  • 20. Hoarseness of voice Deafness Ascites Pericardial & pleural effusion Carpel tunnel syndrome Impotence Galactorrhoea & Amenorrhoea Cardiac failure Psychosis Prof. Tariq Waseem
  • 23.  Depression  Dementia  Parkinsonism  Proximal Myopathies Prof. Tariq Waseem
  • 24.  Hypercholesterolemia  Infertility – Menstrual Irregularities  Diabetes mellitus Prof. Tariq Waseem
  • 25. Primary Test TSH Additional Test Free T4 Prof. Tariq Waseem
  • 26. TSH raised (>3.5-5.5 according to the lab) Free T4 decreased Total T4 decreased Prof. Tariq Waseem
  • 27.  TSH , free T4 , free T3 ,  Ultrasound of thyroid – little value  Thyroid scintigraphy – little value  Anti thyroid antibodies – anti-TPO Prof. Tariq Waseem
  • 28.  CPK ,  AST  LDH  Cholestrol ,  Triglycerides   Anemia: Normochromic normocytic/macrocytic / microcytic  Increased serum prolactin  Hyponatremia Prof. Tariq Waseem
  • 29. Sinus Bradycardia Low voltage Prolongation of the PR interval Bundle branch blocks Flattening or inversion of the T wave Ventricular premature contractions (VPS) Sustained or non-sustained attacks of ventricular tachycardia (VT) Prolongation of the QT interval Prof. Tariq Waseem
  • 30. Primary hypothyroidism Transient Recovery from NTIS Pituitary adenoma Primary adrenal insufficiency T4 resistance TSH resistance at receptor level Prof. Tariq Waseem
  • 31. Central hypothyroidism Imaging indicated to distinguish hypothalamic from pituitary disease Evaluate for 2dary adrenal insufficiency Prof. Tariq Waseem
  • 32.  Improvement of symptoms  Normalization of TSH  Reduction of goiter  Avoid over supplementation :  risk of A-fib in elderly  risk of bone loss Prof. Tariq Waseem
  • 33. Algorithm for Hypothyroidism Measure TSH Elevated TSH Normal TSH Measure FT4 Considering Pituitary Normal Low No Yes Sub-clinical hypo TPO + TPO - T4 repl Annual FU Primary hypothyroid TPO + TPO - No tests Measure FT4 Low Normal No tests Evaluate Pituitary Sick Euthyroid Drugs effect Hashimoto Others Prof. Tariq Waseem
  • 34.  Adverse Effects ◦ Angina in patients having occult IHD ◦ Osteopenia  Contraindicated ◦ Acute MI ◦ Treatment of obesity ◦ Uncontrolled HTN Prof. Tariq Waseem
  • 35.  Goal : Normalize TSH level regardless of cause of hypothyroidism  Treatment : Once daily dosing with Levothyroxine sodium (1.6µg/kg/day- 1.8ug/kg/day)  Monitor TSH levels at 6 to 8 weeks, after initiation of therapy or dosage change Prof. Tariq Waseem
  • 36.  Dose of Levothyroxine depends on the degree of Hypothyroidism, Age & General health condition of the patient  Usually daily replacement dose is 1.6µgm/Kg body weight  Start with Low Dose Prof. Tariq Waseem
  • 37.  Levothyroxine ◦ If no residual thyroid function 1.5 μg/kg/day ◦ Patients under age 60, without cardiac disease can be started on 50 – 100 μg/day. Dose adjusted according to TSH levels ◦ In elderly especially those with CAD the starting dose should be much less (12.5 – 25 μg/day) Prof. Tariq Waseem
  • 38.  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% -50%↑ in dose), safe in lactating mother  Presence of cardiac disease (start alt. day Rx) Dosage Adjustments Prof. Tariq Waseem
  • 39. 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  Decrease in cholesterol level Prof. Tariq Waseem
  • 40. Serum TSH levels should be measured after 6-8 weeks of therapy and dosages should be adjusted accordingly Target TSH levels should be between 1-2 mU/l Once a stable TSH is achieved, it should be estimated every year Prof. Tariq Waseem
  • 41.  Obtain baseline FT4, TSH, LFT, CBCs before initiation of therapy  Repeat FT4 and TSH after 4-6 weeks on therapy and 4-6 weeks after adjustments  Once euthyroid state obtain thyroid function test after 3-6 months Prof. Tariq Waseem
  • 42. During pregnancy requirement of thyroxin increases by 25-50µg/d during pregnancy Even on mild Thyroxin hormone deficiency there are chances of low IQ and developmental delay of the child Hypothyroid And pregnancy Prof. Tariq Waseem
  • 43. Thyroid Hormone exists in two forms : Free (Active) & Bound (with thyroxine binding globuline). In Pregnancy increased Estrogen, increases TBG which in turn increases Total T4 & T3 level However Free T4, Free T4 REMAINS NORMAL. SO Free T4 should be used in the treatment and follow up during pregnancy & not total T4 Prof. Tariq Waseem
  • 44.  Same for the non-pregnant pt  Goal is to normalize TSH  Adjust dose at 4 week intervals  Should check TSH levels every trimester in pts with hypothyroidism Prof. Tariq Waseem
  • 47.  Occurs in previously: undiagnosed hypothyroidism inadequately treated hypothyroidism elderly patients more susceptible MEDICAL EMERGENCY Prof. Tariq Waseem
  • 48.  Infection/sepsis  Drugs…(sedatives, antidepressants, anesthetic drugs)  Cardiac failure/ MI  Respiratory failure/ pneumonia  CVA  GI bleed  Hypoglycemia  Dilutional hyponatremia  Hypoxia/ hypercapnia Prof. Tariq Waseem
  • 49. Signs and Symptoms :  Hypothermia  Coma  Seizures  Other features of hypothyroidism  Usually older age  Bradycardia, ↓ Na,↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑ CPK  ↓ EKG voltage Prof. Tariq Waseem
  • 50.  Treatment ICU transfer, IV levothyroxine 500 µg bolus followed by 50-100µg/d (same dose can be given through NG tube), antibiotics, ventilation, hydrocortisone IV, passive warming, careful volume management, correction of hypoglycemia and hyponatremia Prof. Tariq Waseem
  • 51. When being crazy is not in your head BUT IN THYROID Delirium With Auditory Hallucinations & Paranoid Delusions Takes The Form Of Psychotic Depression Or Pure Psychosis. No Cognitive Impairment Treatment- Thyroxine Prof. Tariq Waseem
  • 52. Sick Euthyroid Syndrome  Total T3 reduced  FT3 reduced  Total T4 reduced  FT4 Normal  TSH Normal  Clinically Euthyroid Prof. Tariq Waseem
  • 53.  Women > 60  women with a family history of thyroid disease,  prior thyroid dysfunction,  symptoms suggestive of hyperthyroidism or hypothyroidism, abnormal thyroid gland on examination,  type 1 diabetes  personal history of autoimmune disorder Prof. Tariq Waseem
  • 54. Prof. Tariq Waseem Abandoned British Era Railway Track Pind Dadan Khan Salt Range Punjab Pakistan Mudat se koyi ayaa naa gaya Wiran paree hai Ghar Ki Fiza