A Nurse Is Reviewing Laboratory Values for a Client Who Reports Fatigue and Cold Intolerance
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A 53-yr-old woman presents to her master care provider with complaints of fatigue, weight gain, and constipation. She states that her weight has gradually increased over the last year despite no alter in her activity level or eating habits. She works roughly 8 hours a solar day as a nutrition assistant, merely she falls comatose as soon as she gets home in the afternoon.
She lacks motivation to do annihilation during the weekend, and notes that she does not experience like herself. Upon questioning, the patient reports the following changes: thinning of her scalp hair, breakable nails, dry peel, and common cold intolerance. Physical exam confirms dry out pare, breakable nails, fibroid and dry hair, and intestinal distension. The only medication she takes is a multivitamin daily. She has a positive family unit history for autoimmune disorders and stroke.
Normal Thyroid Beefcake and Physiology
The thyroid gland is a minor, butterfly-shaped gland located in the neck, nether the trachea.1 The thyroid functions every bit an endocrine gland and produces thyroid hormones and calcitonin, which are responsible for decision-making metabolism, growth, and serum electrolyte concentrations.1
Similar to other endocrine glands, the thyroid has a regulatory feedback system that starts in the hypothalamus, where thyrotropin-releasing hormone is released into the hypothalamic-hypophyseal portal system and transported to the anterior pituitary gland.2 Thyrotropin-releasing hormone then stimulates the pituitary gland to release thyroid-stimulating hormone (TSH).2 TSH travels to the thyroid and binds to receptors located on the follicular cells of the thyroid gland, where it activates a cascade of events inside the follicular cells that ultimately crusade the release of thyroxine (T4) and triiodothyronine (T3), the thyroid hormones.two,three It is important to note that although the thyroid does produce and release both T4 and T3, almost of T3 is made in the periphery via the deiodination of T4.iii
This cascade of hormones is regulated past a negative feedback organization: when the levels of T4 and T3 increment in the bloodstream, they travel back to the hypothalamus and pituitary to signal them to end releasing their respective hormones.2 When the levels of T4 and T3 decrease, the hypothalamus and pituitary return to secreting thyrotropin-releasing hormone and TSH, respectively.two
Epidemiology of Hypothyroidism
Hypothyroidism, the condition in which the thyroid gland does not produce plenty hormone, occurs in approximately 4.6% of the population in the Us.4 The vast majority of cases involve women (85%).1,3 Thyroid deficiency compromises well-nigh all trunk functions, and if left undiagnosed or untreated, it tin lead to infertility, Hashimoto encephalopathy, and myxedema coma.iii,5-7
Autoimmune dysfunction is i of the major causes of thyroid disease.8 In the instance of hypothyroidism, Hashimoto thyroiditis is the nigh mutual autoimmune presentation. Information technology is characterized by infiltration of the thyroid by T and B lymphocytes.8 This leads to thyroiditis, an inflammatory reaction of the thyroid gland that leads to the production of antibodies to thyroid antigens, thyroid peroxidase, and thyroglobulin. Ultimately, the follicular cells of the thyroid are destroyed, thereby interfering with thyroid hormone synthesis.8
Take a chance factors for developing Hashimoto thyroiditis include iodine consumption, smoking, radiation exposure, female sex, aging, and genetics.viii Those with autoimmune thyroid disease are more probable to have other autoimmune disorders (polyautoimmunity). Polyautoimmunity is and then common that guidelines now recommend searching for other autoimmune disorders in patients with autoimmune thyroid affliction, as well as poor treatment outcomes, before initiating combination therapy for hypothyroidism.8
Signs and Symptoms
The manifestation of hypothyroidism can vary markedly from patient to patient. At this time, no clear guidelines exist for screening for hypothyroidism. The Us Preventive Services Task Force does not recommend screening patients for thyroid dysfunction.ix Other associations, including the American Academy of Family Physicians and the American Higher of Physicians, suggest screening for thyroid dysfunction only in women older than sixty years.10 Some clinicians may notice information technology reasonable to screen all patients at risk for hypothyroidism.x Those at run a risk include patients with other autoimmune disorders, history of radiation exposure, or family history of thyroid affliction; women; and those 60 years of age or older.three
Symptoms of hypothyroidism are nonspecific and reflect the generalized slowing of the metabolic processes and include fatigue, languor, cold intolerance, and weakness.iii Signs and symptoms secondary to matrix glycosaminoglycan aggregating include coarse and dry hair, puffy eyelids and face, enlargement of the tongue, and hoarseness (Table ane).3,11,12 Of note, older patients often present with symptoms that could exist attributed to other conditions, whereas younger patients usually display signs and symptoms more typical of hypothyroidism.12 Physical signs include an enlarged thyroid, bradycardia, hypertension, and slow relaxation phase of deep tendon reflexes.3 Thinning of the outer halves of the eyebrows, also known as Queen Anne sign, and galactorrhea are rare additional findings.3
Clinicians must exclude a multitude of other disorders that mimic hypothyroidism, particularly in older patients. The differential diagnosis includes anemia, other autoimmune disorders, chronic fatigue syndrome, constipation, depression, early menopause, adrenal dysfunction, normal aging processes, and pituitary dysfunction.9,thirteen
Our patient presented early on in the form of her condition and had many of the typical symptoms of hypothyroidism. Her family history of other autoimmune disorders was an additional clue. Her presentation led her provider to club a series of tests to help in diagnosis.
From the Jan/February 2020 Outcome of Clinical Counselor
Source: https://www.clinicaladvisor.com/home/topics/endocrinology-information-center/hypothyroidism-a-clinical-case-review/
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