Case scenario: A 46 year old primary school teacher with a past medical history of celiac disease presented to her local GP complaining of feeling tired and increasingly forgetful. She attributes her fatigue to “too much work at school”. The patient complains of overall muscle aches and stiffness around her neck. She has been gaining weight despite several attempts to control her diet. She reports being plagued with multiple illnesses- sore throats, shingles, toothaches and gum bleeding for the past six months. She is frequently constipated, her skin and hair feel drier. Past history: menstrual irregularities; celiac disease.
Vital signs: blood pressure 130/95 mmHg, pulse rate 80 per minute, respiration rate 16 per minute, and body temperature 36.5℃. BMI: 26.1 Physical examinations: both thyroid lobes are diffusely enlarged with firm consistency. Other signs included: cold dry rough skin and slight non-pitting oedema around the ankles. Laboratory results: Serum TSH level was 15 mU/L (Ref.range:0.4 – 4.5 mU/L), free thyroxine (FT4): 5 pmol/L (10 – 20 pmol/L) and total triiodothyronine (T3): 0.9 nmol/L (0.9 – 2.5 nmol/L) The anti-thyroglobulin (anti-Tg) antibody and anti-thyroid-peroxidase (anti-TPO) levels were significantly elevated; anti-TSH receptor antibodies were negative. Other tests: total cholesterol 7mmol/L (3- 5.5 mmol/L). Complete blood count showed decreased RBC count and low Hb level, liver and kidney function tests were normal. The physician suspects Hashimoto thyroiditis For this assignment, you will take the role of the physician and through answering the questions below, you will offer your reader an overview of the disease and a justification for diagnosing the case as Hashimoto thyroiditis.
Questions: 1- Define hypothyroidism and mention its common causes
2- Describe the general clinical presentation of hypothyroidism and relate to the physiological role of thyroid hormones
3- Interpret the current clinical presentation and assess the test results arguing the case for the diagnosis of Hashimoto thyroiditis. You should highlight the significance of each given test result and clinical presentation. (Your answer should include evidence derived from the history, signs and symptoms as well as the test results)
4- Describe the nature of the condition known as “Hashimoto thyroiditis” highlighting its prevalence and pathogenesis
5- Indicate the most suitable treatment available for this patient based on your understanding of the disease.
Guidelines for writing your case report: Your case report should be written in the form of an essay addressing the above questions. If you prefer to use subheadings for each section of your essay, you can do so to organize your writing. If you decide to use subheadings, do not use the questions themselves as subheadings. You should come up with appropriate subheading for each section of your report. The first paragraph of the essay should ideally be an introduction to hypothyroidism including a definition, classification and a summary of its general causes. The following paragraphs should answer the questions given above in a logical and organised manner with an attempt to make a smooth transition from one topic to another creating a systematic and meaningful interpretation of the case. Questions 1 and 2 are general and should provide a comprehensive overview of the causes and clinical presentation of hypothyroidism. Question 3 is specific to the current case and your answer should include interpretation of the current data. It is useful to describe the clinical presentation (typical/atypical presentation, type of onset- acute, insidious, etc). You should show clear understanding of the clinical use of the test (diagnostic, specific, sensitive, etc). You also need to highlight which tests are diagnostic of hypofunction and which tests help in identifying the cause of the hypofunction. You need to explain the rationale behind ordering each test and the significance of the result. Your interpretation should highlight aspects of strength and weakness of the tests (be critical of the results). You need to reflect an understanding of the diagnostic procedure and the importance of interpreting investigations in the context of the clinical picture. Question 4 is a general question about the disease and again your answer should be comprehensive. When answering question 5, comment on the most suitable treatment for the case highlighting the different treatment modalities available for the disease. Your essay should provide a scientifically based argument of the case. Appropriate references should be embedded in the text and a reference list should be provided at the end of the essay. Please, follow departmental guidelines as to how to style and order your references (Harvard style). You can also refer to http://www.citethemrightonline.com/ for further guidance on referencing. The use of patient directed websites as references (NHS.com, boots.com, mayo clinic .com) is not recommended. The use of these websites as main sources of information always results in an assignment that is superficial, including inaccurate data and of poor academic standard. General guidelines for academic writing should be followed. If in doubt, ask a librarian or seek guidance from a member of the LET. Please, follow the recommended word count. If your report significantly exceeds the recommended length, your teacher will only read up to the recommended count and your grade will reflect the assessed part. Suggested resources: Kortext book for the module Kumar and Clark’s clinical medicine Kierszenbaum A and Tres L (Histology and cell biology) Robbins and Cotran (Pathologic basis of disease) Clinical biochemistry, Nessar ahmed MERK manuals http://www.pathwaymedicine.org/thyroid-hormone-physiology https://opentextbc.ca/anatomyandphysiology/chapter/17-4-the-thyroid-gland/ http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/thyroid/physio.html https://www.ncbi.nlm.nih.gov/books/NBK499850/