Question

A 41-year old patient walks into your endocrinology clinic complaining of the following symptoms:

• increased anxiety/depression
• increased fatigue
• unexpected weight gain
• increased sensitivity to change in temperature
• dry and thin skin
• decreased muscle mass and strength

You ask him about his general lifestyle, and he says that he is a very active person and is an avid runner, weightlifter, and skier. He has never had prior problems with weight gain, fatigue, or anxiety/depression. He noticed that this all happened over the course of a few years and that he is not able to even lift the same weights that he easily used to before.

You run a couple blood tests, including a hormone panel and physical exam, to see what's going on. You get the following results:

Elevated LDL & triglycerides

Bone density is low

TSH: 2.4 mU/L (normal: .45-4.5 mU/L)

Testosterone: 515 ng/dL (normal: 270-1070 ng/dL)

Growth Hormone: .09 ng/mL (normal: .4-10 ng/mL)

Answer the following questions:

1. What else (e.g. other hormones, tests, medical history information) do you think he should be tested for/asked about to get a more accurate picture of what's going on?

2. What do you think the root /source of his symptoms could be coming from? List ALL the possibilities as to what could be going on based on what you know about the endocrine system so far.

3. How would you treat him based on what your suspected diagnosis is? Include both pharmaceutical and lifestyle changes, if applicable.

4. Post-treatment, what would you monitor (e.g. through blood tests, questions) over time?

Answer 1

1. He should be tested for thyroid function tests to get a more accurate picture of what's going on. He should be asked about hair loss and other symptoms of hypothyroidism. He should be asked if he has a history of thyroid surgery.

2. The root/source of these symptoms most probably would be hypothyroidism. All symptoms given here are of hypothyroidism and the TSH value is 2.4 mU/L, which shows the patient is at risk of progressing to hypothyroidism. He has elevated triglycerides and LDL. He has low bone density. All these points to hypothyroidism as the root.

3. He will be treated for a suspected diagnosis of hypothyroidism. The patient will be started on progressive hormone replacement with levothyroxine after confirmation of hypothyroidism. Lifestyle changes' advice given to the patient includes a healthy well-balanced diet, regular exercise, destressing with the help of meditation etc., sound sleep, regular doctor visits, and regular screening tests.

4. Post-treatment, thyroid function test, weight, and all the current symptoms of the patient will be monitored. Triglycerides and LDL will be monitored. Bone density should be monitored.