The patient, a 23-year-old woman, has had a bout of flulike symptoms over the past few weeks.
Most recently, she has become increasingly tired. She is taking birth control pills to control her
menses. Her anterior neck became painful during the past few weeks. The physical examination
results reveal that her thyroid is diffusely enlarged and mildly tender.
Routine laboratory tests Within normal limits (WNL)
Total thyroxine (T4), p. 442 8 mcg/dL (normal: 5–12 mcg /dL)
Free T4 0.5 ng/dL (normal: 0.8–2.7 ng/dL)
Free T4 index 0.4 ng/dL (normal: 0.8–2.4 ng/dL)
Triiodothyronine (T3), p. 449 52 ng/dL (normal: 70–205 ng/dL)
Thyroxine-binding globulin (TBG), p.
12 mg/dL (normal: 1.7–3.6 mg/dL)
Thyroid stimulating hormone (TSH),
32 microunits/mL (normal: 2–10 microunits/mL)
Thyroid scanning, p. 780 Enlarged gland; normal shape, position, and function
of the thyroid gland. No areas of decreased or
Thyroid ultrasound, p. 838 Enlarged gland; normal shape and position of the
Antithyroglobulin antibody, p. 92 1:250 (normal: titer <1:100)
Antithyroid peroxidase antibody,
1:500 (normal: titer <1:100)
immunoglobulins, p. 437
Total T4 measures protein-bound and unbound T4. Because the patient was taking birth control
pills, her TBG was elevated; therefore, her total T4 was normal. Free T4 and FT4 index tests
measure unbound T4. When the free T4 and the FT4 index were measured, they were found to be
low, indicating that the patient had hypothyroidism. The TSH level was elevated because of
primary failure of the thyroid. The thyroid antibodies were elevated, indicating that the patient
had Hashimoto thyroiditis. Her long-acting thyroid stimulator (LATS) levels were normal,
discounting Graves disease as a cause of her diffusely enlarged thyroid. Her thyroid ultrasound
and scan failed to show any localized, defined tumor.
The patient was started on thyroid replacement therapy, and her TSH level returned to normal.
Over the next few weeks, she felt markedly better. Her thyroid pain and tiredness disappeared.
Critical Thinking Questions
1. Why were the thyroid antibodies important in this patient’s diagnosis?
2. What symptoms might she experience if too much thyroid replacement medication were
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