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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

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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.

Studies Results

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),

p. 434

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

increased uptake

Thyroid ultrasound, p. 838 Enlarged gland; normal shape and position of the

thyroid gland

Thyroid antibodies

Antithyroglobulin antibody, p. 92 1:250 (normal: titer <1:100)

Antithyroid peroxidase antibody,

p. 93

1:500 (normal: titer <1:100)


immunoglobulins, p. 437


Diagnostic Analysis

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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