Ms. JB is a 43-year-old book keeper who presents to the GP with severe fatigue.
Take a history of this patient.
HPC:
• Severe fatigue 6 months, decreased ability to keep up to routine work.
• More sleep than usual, dark rings under her eyes.
• Heavier periods, clots - thinks nearing menopause.
• Husky masculine voice - recently.
• Constipation, weight gain 6kg - since 4 months.
• Symptoms worse on gluten - is avoiding it. B12 deficiency? Gluten (make you think of autoimmune disorders e.g. gluten enteropathy, RA. Iron deficiency usually in this CPC).
• Very dry skin, dry hair, cannot tolerate cold (opposite in hyperthyroidism).
• Depression. Tearful, some stress (past depression on SSRI).
• Hot flushes: No, FH: Mother on thyroxine, osteoporosis.
HPC:
• Onset - how long have you been fatigued? Initiating factor?
• Character - worse at a particular time?
• Alleviating factors?
• Timing - experienced before? Constant or intermittent? How long does it last?
• Exacerbating factors?
• Severity?
• Associated symptoms?
• Effect on lifestyle?
- Cold intolerance, apathy, dry skin/hair, constipation, weight gain, weakness, voice change, heavy periods?
- Depressed mood/irritable, loss of interest in hobbies, worthlessness, suicidality?
- Stinking stools/steatorrhoea, diarrhoea, abdominal pain, bloating, vomiting/nausea, weight loss?
- Polyuria, polydipsia?
- Dyspnoea/on exertion, chest pain, weakness, melaena/haematemesis?
- Recent viral illness/infection (fever, cough), myalgia/arthralgia (EBV, RA, fibromyalgia can cause chronic fatigue)?
PMHx:
• Past history of any thyroid problems, diabetes, anaemia, mental health etc?
• Obs/gyn - menstrual history.
PSHx:
• Past surgeries?
Medications:
• Any regular medications?
Allergies:
• Agent, reaction, treatment?
Immunisations:
• E.g. Fluvax, pneumococcal?
FHx:
• Family history of any thyroid problems, diabetes, anaemia, mental health etc?
SHx: • Background? • Occupation? • Education? • Religion? • Living arrangements? • Smoking? • Nutrition? • Alcohol/recreational drugs? • Physical activity?
Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, change in bowel habit?
• UG - dysuria, polyuria, nocturia, haematuria, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?
Perform an exam HR; 60- regular BP; 135/90 RR; 12 T; 36.8 BMI; 27 -Slightly delayed tendon reflex
- Introduction, explanation, consent, wash hands.
- General inspection: mental and physical sluggishness, fatigue/lethargy, weight gain, myxoedema facies, dry thickened skin, deep voice.
3. Vital signs: • HR - may be bradycardic, small volume. • RR - may be bradypnoeic. • BP - hypertension. • Temp - hypothermia. • BMI.
- Hands:
• Cold, dry palms.
• CRT reduced.
• Peripheral cyanosis, swelling.
• Pallor, hypercarotinaemia (decreased hepatic metabolism of carotene).
• Check for proximal muscle weakness by asking patient to abduct arms.
• Sensory loss, thickened carpal tunnel. - Face:
• Alopecia, dry thin hair.
• Yellow discolouration of skin due to hypercarotinaemia.
• Vitiligo. (blotchy skin)
• Eyes - periorbital oedema, loss of outer third of eyebrows, xanthelasma, conjunctival pallor, lid lag, proptosis (as doing thyroid examination)
• Mouth - swelling of tongue, aphthous ulcers, angular stomatitis. - Neck:
• Inspection - ask patient to extend neck. Inspect front/sides - swelling, scars, redness, prominent veins. Ask patient to sip water - watch for upward movement of gland noting its contour, symmetry and inferior border.
• Palpation - isthmus/lobes for any swelling. Ask the patient to swallow and feel the isthmus rising up. If a swelling is seen/felt - comment on size, warmth, shape, consistency, nodules, tenderness, mobility and borders. Pressure on enlarged gland may cause stridor. Palpate the cervical lymph nodes (supraclavicular, posterior triangle). From the front - palpate again with thumb. Check for tracheal displacement. Pemberton’s sign - substernal and retroclavicular goitre.
• Percussion - important if suspecting retrosternal extension of goitre (lower border not felt).
-Auscultate for bruit - Chest
• CVS and RS examination looking for pericardial and pleural effusions. Palpate apex beat. - Legs:
• Ask patient to squat to test for proximal myopathy.
• Non-pitting oedema.
• Test for hung up reflex at the ankle - delayed relaxation of the ankle jerk.
9. CNS: • Carpal tunnel. • Nerve deafness, • Peripheral neuropathy. -Reflexes
- GI
• Inspection/palpation/percussion - tenderness, masses, ascites.
• Signs of malabsorption.
• Rectal/genital examination.
-Mention doing K10 in patient due to depression
What are your provisional and ddx
• Provisional diagnosis: Hypothyroidism (decrease in metabolic activities - constipation, weight gain, masculine voice, heavy periods - all suggestive of decreased thyroid function). • DDx: - Anaemia. -Depression/anxiety. - Coeliac disease. - Anaemia. - Chronic fatigue. - Diabetes mellitus. - Menopause -Sleep apnoea - Addison's disease--> due to high BP with normal HR
What ix would you order
• FBC - Hb (anaemia).
• Iron studies- mild iron def.
• Lipids - cholesterol and triglycerides increased.
• B12/folate- normal
• BSL- normal
• TFTs - TSH 80 (normal is 0.1-3.5), T4 3.9 (9-16).
• Thyroglobulin/peroxidase antibodies- 364 (less than 6)
-TSH receptor antibody= 5.5 (less than 1)
• Ultrasound - if goitre present.
• Thyroid biopsy - first line for patients with thyroid nodules.
• Gliadin antibody.
• K10
-ECG= normal
-UEC= normal
-Cervical screening test (pap smear)
-Sleep study (very second line)
What tx is required
• Thyroxine*
- 1.6 μg/kg
- Start with lower dose then increase.
- Review TFTs after 4-6 weeks - long half-life of 7 days.
- Once stabilised → annual review.
- Taken PO in the morning 1 hour before food (need an empty stomach to absorb).
- Stored in fridge.
- If the patient has CVS risk factors - be wary of thyroxine - can worsen heart - start a lower dose.
• Iron supplementation.
What is the patients problems list
- Hashimoto’s thyroiditis.
- IDA.
- Fatigue.
- Possible gluten intolerance
- Depression.
- Weight gain.
- Relationship with husband - not supportive.
What is subclinical hypothyroidism
• TSH high, T4 normal → subclinical hypothyroidism. - If TSH > 10 - treat with thyroxine. - If TSH 5-10 - 2 options: • Treat with thyroxine OR • Monitor for 6 months and reassess. - If TSH < 5 - don’t treat.
