khalil m alsoutary ,md asst professor ,internal medicine€¦ · history taking part 1 khalil m...
TRANSCRIPT
![Page 1: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/1.jpg)
History taking Part 1
Khalil M Alsoutary ,MD
Asst professor ,Internal Medicine
American Board in Medicine and Endocrinology
Balqa Applied University, June 2019
![Page 2: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/2.jpg)
Reasons why patients visit
doctors
• They have reached their limit of tolerance
• They have reached their limit of anxiety
• They have problems with living presenting as
symptoms
• For prevention
• For administrative reasons e.g sick leave,
employment physical exam
![Page 3: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/3.jpg)
Patient centered medicine
• The first and major part of consultation is
talking with the patient
• Communication is integral to the clinical
examination,
• It is most important at the start of interview
to gather information and at the end of
interview to find common grounds and
engage your patient in their management
![Page 4: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/4.jpg)
Effective communication skills
• 1.Improve patient satisfaction
• 2.Improve doctor satisfaction
▪ 3.Improve health by positive support and
empathy:
-Improve health outcomes
-Enhancing the relationship between physician
and patient
▪ 4.Use time more effectively
Active listening help the doctor reconize what is
wrong, and reduces patient complaints
![Page 5: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/5.jpg)
Beginning• Setting up
• How long will you have usually 15 minutes for
follow up,30 min for new patient
• Seating arrangemen: non -confrontational way,
talk to patient face to face
• Non verbal communication:
• Your attitude and dress influence the patient
from the beginning ,all the time be professional
in dress and behaviour
• Avoid interruptions such as answering
telephone
![Page 6: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/6.jpg)
Active listening
• Encourage patient to talk by looking
interested
• Good eye contact ,not being buisy with
writing on computer, or answering phone
• Give the patient time to tell his symptoms in
his own language with minimal interruption
![Page 7: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/7.jpg)
![Page 8: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/8.jpg)
• Open questions encourage patient to talk:
• E,g (can you tell me what happened to
bering you to the hospital ?)
• Closed questions e.g: have you had cough
today?, For how long do you have back
pain?
![Page 9: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/9.jpg)
Understanding your patient context
• You must understand your patient`s context as
part of gathering information:
• Where they live
• Who they live with
• Where they work?,what actually tey do clerical
versus field work
• Explore your patient job,job details
• Who do their activities of daily living e.g
shopping,cooking,taking shower etc.
![Page 10: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/10.jpg)
Engaging your patient
• Make sure your patient is involved in each
decision, make suggestions,and encourage
them to contribute their thoughts
![Page 11: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/11.jpg)
Taking with patients
• Speak clearly and audibly
• Do not use jargon
• Do not use unnecessary emotive words
• Listen to their story
• Find out about them as people
• Clarity
• Negotiate mutual plan
• Summarize
![Page 12: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/12.jpg)
![Page 13: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/13.jpg)
Breaking Bad news
• It is one of themost difficult communication task
you will face
• Speak to the patient in a quiet, private environment
ideally with a partner or family member
• Be honest
• Go at the patient pace,find out how much they
want to know, and check their understanding
![Page 14: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/14.jpg)
Communication difficulties
• To establish some form of communication
with deaf or patient who speaks foreign
language
• 1.use uinterpretor
• 2.write things down
• Employ sign language لغة االشارة
• Involve someone who is used to
communicate with the patient
![Page 15: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/15.jpg)
Transcultual awareness
• Appropriateness of eye contact
• Appropriateness of hand gestures
• Personal space
• Physical contact between sexes: hand shake
• Cultures and beliefs surrounding illness
• What should happen as death approach
![Page 16: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/16.jpg)
Terms used by patients that should
be clarified• Allergy Eczyma
• Angina Fits
• Arthritis Heart attack
• Diarrhea migraine
• Dizziness Vertigo
• Pleurisy
![Page 17: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/17.jpg)
Pain threshold
DecreasedIncreased
Sleep deprivationExercise
DepressionAnalgesia
Financial and personal worriesPositive mental attitude
Anxiety and fearPersonality
Past experience
![Page 18: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/18.jpg)
The effects of chronic pain
questions
Money
• Have you had lost money
• because of illness
•Leisure RelationshipsHave you had to give up any How have this affected
your Of your hobbies because your relationship with
of Pain ? your partner and family?
Work :Have you had to take
time off work
![Page 19: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/19.jpg)
![Page 20: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/20.jpg)
![Page 21: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/21.jpg)
![Page 22: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/22.jpg)
![Page 23: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/23.jpg)
![Page 24: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/24.jpg)
![Page 25: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/25.jpg)
![Page 26: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/26.jpg)
![Page 27: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/27.jpg)
![Page 28: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/28.jpg)
![Page 29: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/29.jpg)
![Page 30: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/30.jpg)
![Page 31: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/31.jpg)
Thyroid Function Tests
interpretation
Khalil Alsoutary,MD,FACE
Endocrinologist
May 2019
![Page 32: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/32.jpg)
Thyroid Function
•chemistry & pathophysiology
•causes of hyper-& hypothyroidism
•thyroiditis
•tests of thyroid function
•test strategies
•case studies
![Page 33: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/33.jpg)
![Page 34: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/34.jpg)
![Page 35: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/35.jpg)
![Page 36: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/36.jpg)
![Page 37: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/37.jpg)
![Page 38: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/38.jpg)
Chemistry & Pathophysiology
•T4 - 80 ug/d produced by the thyroid gland
•T3 - 30 ug/d; 80% by peripheral action of
5’ deiodinase
•T4 - 99.97% bound & T3 99.0% bound to
TBG, albumin & pre-albumin
•FT4 & FT3 exert negative feedback on TSH
•Hypothalamic TRH modulates feedback
setpoint
![Page 39: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/39.jpg)
Thyroid Binding Proteins
•INCREASES
•estrogen/pregnancy
•methadone & heroin
•acute & chronic active
hepatitis
•hereditary
•DECREASES
•glucocorticoids
•androgens
•L-asparaginase
•nephrosis
•hereditary
![Page 40: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/40.jpg)
Causes of Hyperthyroidism
•Graves Disease
•Functioning Thyroid Nodule (Plummer’s)
•Toxic Multinodular Goiter
•Thyroiditis
•Factitious Hyperthyroidism
•Drug Induced: iodine, amiodarone, lithium
•Pituitary-Hypothalamic origin
![Page 41: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/41.jpg)
Causes of Hypothyroidism
•Chronic Thyroiditis (Hashimoto’s)
•After radioiodine,surgery or antithyroid
drug therapy
•Drugs: amiodarone, lithium,
•Congenital - 1in 4000 births:
![Page 42: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/42.jpg)
Free T3Free T4TSHcondition
highV.highundetectablePrimary
hyperthyroid
v.highnormalundetectableT3 toxicosis
highhighincreasedSecondary
hyperthyroidism
NNlowSubclinical
hyperthyroidism
Thyroid hormone tests in
various disorders
![Page 43: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/43.jpg)
IncreasedIncreasesIncreased
or N
Thyroid H
Resistance
Decreased or
N
decreasedIncreasedPrim
hypothyroidi
sm
Decreased or
N
DecreaseDecreased
or N
Secondary
hypothyroidi
sm
Free T3Free T4TSHcondition
![Page 44: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/44.jpg)
Risk of Overt Hypothyroidism in
a 60-Year-Old WomanAb neg
Ab pos
Hy
po
thy
roid
ism
(%
)
2 5 10TSH
Vanderpump Met al: 2003
![Page 45: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/45.jpg)
Thyroiditis
•Acute suppurative
•Subacute: granulomatous
•Subacute: lymphocytic
- 10% postpartum (silent)
- hamburger toxicosis
•Chronic Thyroiditis (Hashimoto’s)
![Page 46: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/46.jpg)
Subacute Thyroiditis
•Granulomatous
•post viral
•painful thyroid
•systemic symptoms
•high sed rates
•Lymphocytic
•painless
•simulates Graves
•normal or slightly
elevated sed rates
![Page 47: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/47.jpg)
Thyroid Function tests
•TSH-2sd generation
•FT4
•TSH-3rd generation
•Total T3
•RAI uptake
•antithyroid antibodies
•Total T4
•T3 Resin Uptake
•Free T4 Index
•TRH Stimulation Test
•Thyroglobulin
![Page 48: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/48.jpg)
TSH
•Immunometric Assays
- Analytical Sensitivity (CV </= 20%)
- 1st generation: 1.0 uU/mL
- 2sd generation: 0.1 uU/mL
- 3rd generation: 0.01uU/mL
![Page 49: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/49.jpg)
TSH•INCREASES
•hypothyroidism
•inadequate T4 Rx
•lithium, iodine, antithyroid drugs
•nonthyroidal illness
•DECREASES
•hyperthyroidism
•L-dopa, dopamine,
steroids
•excessive T4 Rx
•2sdry hypothyroidism
•nonthyroidal illness
![Page 50: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/50.jpg)
•Primary:
–Principal Cause and Largely Autoimmune
•Central
–Secondary + Tertiary
•More recently recognized etiologies
–Chemotherapeutic Agents
•Ipilimumab, Bexarotene, Sunitinib (tyrosine kinase
inhibitors)
–Consumptive hypothyroidism
Causes of Hypothyroidism
![Page 51: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/51.jpg)
Anti-Thyroid Antibodies
•Markers of Chronic Thyroiditis
•Anti- Thyroglobulin Antibodies
–Does not Correlate with hypothyroidism
•Anti-Thyroid Peroxidase Antibodies
(formerly known as Anti-microsomal
Antibodies)
–Correlate with the development of
hypothyroidism
![Page 52: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/52.jpg)
Principal Lab Tests to Diagnose and Monitor
Hypothyroidism
•Free Hormone Hypothesis
–Only free hormone metabolically active and determines
thyroid status (not total which is largely bound to
binding proteins)
–Gold standard: Equilibrium Dialysis
Estimates
Free Thyroxine Assays - Use anti T4 Antibodies
–Free Thyroxine Index = Total T4 x T3 UPTAKE
–T3 Uptake ESTIMATES % free hormone
![Page 53: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/53.jpg)
Severity of Primary Hypothyroidism by
Thyroid Levels
TSH rises first and abruptly
Decline of T4 and
T3 slower and later
![Page 54: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/54.jpg)
![Page 55: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/55.jpg)
Approach to SC HypothyroidismSerum TSH
5-10 mIU/L >10 mIU/L
Repeat TSH, FT4, TPOAb Begin T4 Rx
Normal tests
Follow
TSH & TPOAb+
FollowT4 Rx if...• Goiter• Hyperlipide
mia• Infertility• Young pt
![Page 56: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/56.jpg)
Rising TSH By Age in Cross-sectional Studies
![Page 57: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/57.jpg)
• The MEAN rises with age
• The upper limit of normal
• A “natural” rise of TSH
•
• Should Be USED a BMD for
0
8
7
6
5
4
3
2
1
20-29 30-39 60-69 70-79 80+
NHANES IIINormal Range (2.5 - 97.5 Centile) by Decade
lower TSH limit stayrelatively constant with age
MEAN
rises with age
with age? (survivalBenefit?)Is there a progression toatrophic hypothyroidismwith age that is included innormal
the normal range in
40-49 50-59
AGE
![Page 58: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/58.jpg)
![Page 59: Khalil M Alsoutary ,MD Asst professor ,Internal Medicine€¦ · History taking Part 1 Khalil M Alsoutary ,MD Asst professor ,Internal Medicine American Board in Medicine and Endocrinology](https://reader035.vdocuments.net/reader035/viewer/2022081615/5fd51ccdd369052f52367a06/html5/thumbnails/59.jpg)
Thyroid Function: References
•Klee, G & Hay, I: Biochemical Thyroid Function Testing. Mayo Clin Proc
1994;69:469-70
•Lazarus, JH: Hyperthyroidism. Lancet
1997;349: 339-43
•Lindsay, RS, Toft, AD: Hypothyroidism. Lancet
1997; 349:413-17
•Smith, SA: Commonly asked questions about Thyroid Function
Mayo Clin Proc 1995; 70:573-577
•Dayan, C: Interpretation of Thyroid Function Tests
Lancet 2001; 357:619-624
•Fatourechi, V: Subclinical Thyroid Disease
Mayo Clin Proc 2001;76:413-417