1. Which of the following is the most
Thyroid stimulating hormone (TSH)
common cause of hypothyroidism
worldwide?
A. Graves disease
B. Hashimotos thyroiditis
C. Iatrogenic hypothyroidism
D. Iodine deficiency
E. Radiation exposure
2. A 23-year-old college student is seen in
your practice for medical management
of panhypopituitarism after a resection
of craniopharyngioma as a child. She
reports moderate compliance with her
medications but feels generally well. A
TSH is checked and is below the limits of
detection of the assay. Which of the
following is the next most appropriate
action?
A. Half current dose of levothyroxine
B. Do nothing.
C. Order a free T4 level.
D. Order MRI of her brain.
E. Order thyroid uptake scan
3. A 33-year-old obese woman complains
of tiredness. She has recently given
birth to a healthy baby boy and is
enjoying being a mother. However, she
is becoming more reliant on her partner
for support as she always feels
exhausted and often becomes
depressed. The patient has a poor
appetite and often does not finish her
meals, despite this she has gained 5 kg
in the last 2 weeks. The most likely
diagnosis is:
A. Postpartum depression
B. Eating disorder
C. Hyperthyroidism
D. Hypothyroidism
E. Occult malignancy
4. A 47-year-old woman is referred to the
endocrine clinic complaining of a two
month history of tiredness. Despite
wearing several items of clothing, the
patient appears intolerant to the room
temperature. She has noticed an
increase in her weight, particularly
around her waist. The most appropriate
investigation is:
A. Radioiodine scan
B.
C. Total tetraiodothyronine level (T4)
D. Tri-iodothyronine level (T3)
E. Ultrasound scan of the neck
1. D. Iodine deficiency remains the most
common cause of hypothyroidism
worldwide. It is present at relatively high
levels even in the developed world including
Europe. In areas of iodine sufficiency,
autoimmune disease (Hashimotos
thyroiditis) and iatrogenic hypothyroidism
(treatment of hyperthyroidism) are the most
common causes.
2. C. The patient has panhypopituitarism and
is unable to make TSH; thus her plasma TSH
level will always be low, regardless of the
adequacy of her T4 replacement. A free T4
level will allow the determination of whether
her plasma level is in the normal range of
thyroid hormone. This, coupled with her
symptoms, will aid in the determination of
proper levothyroxine dosing. There is no
evidence of recurrent disease clinically; thus
MRI is not useful. She is unlikely to have
primary thyroid disease, and T4 level is
unknown presently, so thyroid uptake scan
is not indicated at this time.
3. D. Hypothyroidism (D) is a common disease
with a higher prevalence in females and is
usually a primary disorder affecting the
thyroid gland itself. Thyroid hormones
control the metabolic rate in many tissues;
underactivity produces symptoms which are
often insidious. These include tiredness,
depression, cold intolerance, constipation
and weight gain. The main causes include
iodine deficiency, autoimmune pathology
such as Hashimotos thyroiditis and, in
females who have recently given birth,
postpartum thyroiditis. Postpartum
depression (A) is often accompanied by
confusion and is characterized by low mood,
anhedonia and anergia. Severely affected
patients can have delusional thoughts about
their newborn child, such as it being evil,
and even progress to thoughts of harming
the child or suicidal ideation. Most
malignancies (E) result in considerable
weight loss though this is dependent on the
type of cancer and often symptoms provide
clues as to the location, e.g. neurological
problems.
4. B. This patient is probably suffering from
hypothyroidism. The most appropriate first
line investigation is measurement of TSH (B)
as this indicates if a primary disease
affecting the thyroid is present. In a patient
with symptoms of hypothyroidism due to a
primary disorder of the thyroid, the TSH
would be elevated. Similarly, in symptoms of
hyperthyroidism due to a primary
abnormality of the thyroid, the TSH would less commonly than T4 and hence is
be depressed. The total T4 level (C) would measured less often. A radioiodine scan (A)
be decreased in hypothyroidism and is useful for studying causes of
elevated in hyperthyroidism, but this could hyperthyroidism, such as Plummers
be due to abnormalities of TSH secretion or disease. Ultrasound scan of the neck (E) is
a primary disorder of the thyroid. most useful for differentiating between solid
Hyperthyroidism due to elevated levels of and cystic nodules; these usually do not
tri-iodothyronine level (T3) (D) occurs much alter thyroid function.