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Interpretation of Thyroid Function Tests

May 16 | 2:00 PM

Thyroid function tests (TFTs) must always be evaluated in the context of the patient's clinical status: hypothyroid, euthyroid, or hyperthyroid. TH (thyroxine, T4; triiodothyronine, T3) levels are typically consistent in any given person and reflect the'set-point' of the hypothalamic–pituitary–thyroid (HPT) axis in that person. Thyroid status changes are frequently accompanied by variations in TH and TSH levels (eg raised T4 and T3 with suppressed TSH in thyrotoxicosis; low T4 and T3 with elevated TSH in hypothyroidism). Let's look at how to interpret TFTs and their clinical relevance. Join us live with Dr. Rohit Jacob.

[Music] uh to this evening session on interpretation of thyroid function test uh the speaker with us this evening is dr david checkout uh he's a consultant physician and intensivist with uh craft or hospital and ar medical center coaching he's very passionate about teaching uh and he's now conducted many sessions on netflix as well so i'll start with your presentation and the floor is on your own okay uh so uh good evening everyone so today we are going to start about interpretation of thyroid function test so as we all know that in a general physician practice or in a general medicine practice thyroid is something which we commonly check and it is something which we know a lot about but still the knowledge always still remains incomplete because of the vast uh data that it covers so so to start with let's just go into the beginning of the physiology of how her thyroid gland functions so just before beginning the thyroid function test so uh yeah so just uh you can zoom in and see about the synthesis of the thyroid hormones so as we all know basically there are two main thyroid hormones the triado thyronine and thyroxine so if you see here the first step that comes is that thyroglobulin is synthesized and discharged into the follicle lumen okay now once the thyroid globulin is uh synthesized and discharged there is trapping of the iodide ions that take place and there is organification of the iod which later is taken up into the colloid the iodine enters the follicle lumen where it is attached to the tyrosine in colloid and it forms dye and mono iodo tyrosine once the dihydrotyrosine and monohydrotyrosine is formed these iodinated tyrosines are linked together to form t3 and t4 the thyroglobulin colloid is endocytosed and combined with a lysosome the lysosomal enzymes cleave t4 and t3 from thyroglobulin colloid and hormone diffuses from follicle cell into the bloodstream so that is how t3 and t4 are released so in short if you see the first step is the iodine uptake then there is organification of the iod then the organification of the iodine combines with the tyrosine to form mono and diodo tyrosine then it forms t3 and p4 and the t3 and t4 are then released into the circulation one thing that you majorly need to remember is that 99 of the thyroid hormones are protein bound either it is in the form of thyroid binding globulin or it is combined with albumin so 99 is the combined form and only one percent is the free hormone form so naturally when you check the thyroid function test it is always better to check the free hormones rather than the total t3 and total t4 the main reason being that free t3 and 3 t4 are the ones which give actual and the most apt result in a thyroid function test now if you see if we come to the clinical features of the thyroid disease there are basically categorized into hypothyroid hyperthyroid and graves disease if you see the hypothyroidism the symptoms include lethargy weight gain cold intolerance constipation hair loss dry skin depression bradycardia memory impairment menorrhagia these are just few of the symptoms to be mentioned but there are whole lot of symptoms because thyroid gland controls major part of all the functions of the human body then coming to the hyperthyroid symptoms which include tachycardia palpitation hyperactivity weight loss with increased appetite heat intolerance sweating diarrhea fine tremors hyperreflexia goiter palmar erythema onycholysis muscle weakness and wasting oligomenorrhea and amenorrhea graves disease include exophthalmos proptosis chemosis diffuse symmetrical goiter pre-tibial mexidima other autoimmune conditions and thyroid group now one thing that you need to remember is the difference between thyrotoxicosis and graves disease let me tell you every thyroid toxicosis is not graves disease and every graves disease may or may not be thyrodoxycosis so basically graves disease is a combination of three major symptoms one is the thyroid ophthalmo uh is the thyroid proctosis second one is the pre-tibial mixed edema and third is the thyroid acropatry so if these three collective symptoms are present then only you can call it as graves disease now coming to how to approach a case of or how to approach thyroid function per se so if you start with the first way is to check the tsh level once you know that a patient has got high tsh the next step is to measure the t4 if a patient has low tsh again you measure the t4 now once you get high tsh and then you measure the t4 if the t4 level remains high then the possibility of it being a secondary hyperthyroidism example pituitary adenoma so in such a case which is called as the secondary hyperthyroidism or central hyperthyroidism so the cause is always at the level of the pituitary so pituitary adenoma is one common differential that can be there next step is you can check the cortisol fsh lh and prolactin now let's say you have a high tsh and you have a normal t4 this is a case of subclinical hypothyroidism another problem another case scenario is high tsh and low t4 then you have a suspicion of a primary hypothyroidism so the cause for primary hypothyroidism could be autoimmune thyroiditis iodine deficiency thyrotectomy post surgery post ablation external beam radiation and so on and so forth once you get the diagnosis to primary hypothyroidism the next step is to check for the antibody levels that is the anti-tpo or anti-thyroglobulin antibodies in case they are positive then the suspicion would be most likely autoimmune thyroiditis now let's say the patient is having low tsh if the patient has low tsh the next step is measure the t4 levels if the t4 levels are high it is primary hyperthyroidism example graves disease toxic multinodular goiter or toxic adenoma in such a case you go for the antibody testing that is the tsh receptor antibody levels or anti-tpo antibody positive in such a case you have a suspicion of likely graves disease now one thing that you need to remember is that tpo antibody is positive in both hypo and hyperthyroidism so basically the differential lies within the symptoms now let's say you have symptoms of uh thyrotoxic horses and still if anti-tp antibodies positive it does not mean it is hypothyroidism possibility of hyperthyroidism is more and another possibility is a subacute thyroiditis now a let's say a patient comes with extreme weight gain at the same time patient has heat intolerance so that means patient has a mixed feature of hypo and hyperthyroidism this is a classical case of subacute thyroiditis or there could be possibility of a goiter where there is a hot nodule and a cold nodule because of the hot nodules there are hyperthyroid symptoms because of the cold nodule there are hypothyroid symptoms so it's important to correlate the clinical features along with the investigational results then only you can come to a conclusion now let's say you have low tsh and then you measure t4 and the t4 level comes to be normal then it is a case of subclinical hyperthyroidism if a patient has low tsh as well as low t4 then it is secondary hypothyroidism or what we call as central hypothyroidism which is a very rare case scenario now this is a summary of how to interpret a thyroid function test let's say tsh normal ft3 normal ft4 normal the condition is normal if tsh is low and ft3 ft4 are high then it is a classical if tsh is low and ft3 and ft4 are high then it is a classical case of hyperthyroidism if tsh is low and ft4 ft3 is normal then it is a classical case of subclinical hyperthyroidism if tsh is low ft4 is normal and ft3 is high then it is a case of t3 toxicosis if tsh is low ft4 is high but ft3 is normal then there is a possibility of thyroiditis p4 ingestion or hyperthyroidism in the elderly with comorbid illness if tsh is low ft4 is low and ft3 is also low it is eu thyroid 6 syndrome or central hypothyroidism this is a common scenario where you see that if a patient comes with let's say multiple infections or patient has a rds or patient that's got pneumonia or patient that's got gastroenteritis or something like that and when you check for the thyroid profile it comes as tsh low ft4 low and ft3 low so you yourself remain confused as to what is happening the most important point you need to remember with respect to thyroid is that do not check the thyroid status when patient is in stress the stress include active infections or any kind of illness it is important that the patient recovers from the illness and then you check the thyroid status because any infection or any stress condition artifactually suppresses the tsh so this is something which you need to remember do not check the thyroid status especially when patient is having active infection or stress next scenario is when tsh is high fd3 is normal and fd4 is also normal this is a case of subclinical hypothyroidism or it is recovery from eu thyroid 6 syndrome if tsh is high and ft3 and fd4 are low this is classical primary hypothyroidism if tsh is high ft3 is also high and fp4 is also high this is tsh producing pituitary adenoma or what you call a a kind of central hyperthyroidism cause it is not always a pituitary adenoma because you need to further check out fsh lh prolactin and so on and so forth whenever you see a case when tsh is high ft3 is high or fd4 is high this is a case which i would suggest that you personally refer it to an endocrine logist because it requires further evaluation again repeating a different flowchart as to how to approach a case of thyroid let's say you have a patient with clinical symptoms where you're suspecting hyperthyroidism in such a case you order tsh if tsh is low then you go for ft4 remember that if ft4 is normal next step is check for ft3 if ft3 is normal then you monitor tsh at 6 to 12 months interval or sooner if the clinical situation demands it let's say if tsh is low ft4 is normal but ft3 is high this is the classical case of t3 toxicosis also if tsh is normal and ft4 tsh is low and ft4 is high then hyperthyroidism is confirmed which may be t4 or t3 toxicosis this further requires treatment and further requires investigations now let's say you have a patient with normal tsh level in such a case ft3 and ft4 need not be measured unless the clinical symptoms demanded now let's see if a patient is having hypothyroidism if a patient has hypothyroidism then next step or where tsh is high next step is you check for ft4 if ft4 is low hypothyroidism gets confirmed in such a case you start with the medication or you monitor tsh and then you decide what to do next if tsh is high and ft 4 remains normal the next step is that you repeat tsh at 6 to 12 months interval or sooner if the clinical situation demands it so let me tell you one thing very clearly is that if a tsh is low or high you can go for starting the treatment if the clinical situation demands it if you are not sure whether the tsh has increased or decreased uh with respect to you know illnesses or stress then you can wait for some time let's say about no need not wait for six months you can wait for about two to three weeks and then repeat the tsh and then you can decide what to do next a special situation occurs if a patient is above 60 or 65 years old remember in such old age patients tsh always tends to be higher between let's say five to ten all these cases need not be treated so please do not treat a 65 year old patient if tsh is between 5 to 10 and there is no clinical symptomatology also if a patient is below 60 years and tsh is high next step you go for is antibody testing but this is not applicable if the patient is above 60 or 65 years old it is important that more than the antibody testing you correlate with the clinical symptomatology if that persists then only to go for treatment otherwise you can just serially monitor the tsh to look for further rise if when you're not treating it now coming to evaluation of thyroid toxicosis now let's say you measure the tsh and you measured the unbound t4 or what we call as the free default if tsh is low and free t4 is high then it is primary thyrotoxic process as i said earlier you can differentiate thyrotoxicosis with graves disease with the symptomatology if a primary thyroid toxicosis has features of graves disease then you can conclude that graves disease could be the cause for thyrotoxicosis but in case the features are not present then it could be a possibility of multi-nodular goiter or toxic adenoma if any of these two conditions are present then you go for treating it accordingly so how do you go about finding out whether the cause could be anything else apart from graves disease the test lies is the radioactive iodine update after the radioactive iodine uptake you go for a thyroid scan if the thyroid scan shows that a nodule is taking up iodine uptake more than normal then it could be a hot nodule or what would call as a toxic nodular pointer if the radioactive iodine uptake is low then it does not mean that thyroid toxicosis does not exist it means that there could be another cause for thyrotoxicosis which for example could be stimulation by the chorionic gonadotropin this is classically seen in gestational thyrotoxicosis in pregnancy up to the first 16 weeks there is a possibility that the thyroid hormone function is taken over by the hcg hormone which causes increased thyroid hormone production this is called as gestational thyrotoxicosis and gestational thyrotoxicosis does not require treatment this is something which everyone should remember primarily that gestational thyroid toxicosis does not require anti-thyroid drugs for treatment unless it has proceeded beyond 16 weeks if it has proceeded beyond 16 weeks then you have to do a confirmatory antibody testing to rule out graves disease and if graves disease is present then only go for treating that particular hyperthyroidism now coming to the second situation when tsh is low and unbound t4 remains normal then next step is that you measure the free t3 if free t3 is high it is t3 tyrotoxicosis if free t3 is normal it is subclinical hyperthyroidism which requires follow-up in 6 to 12 weeks now let's say another situation where tsh is normal or increased and there is high free t4 levels in such a case it could be a central cause where there is a tsa secreting pituitary adenoma or thyroid hormone resistance syndrome which is also called as a referent of syndrome now coming to the next scenario where tsh and free t4 both are normal this requires no further testing now coming to the last slide of the day that is how to approach a patient with thyroid nodule so if you have a solitary or a suspicious nodule then you can by ex clinically examining the patient then next step is you go for checking the tsh level if tsh level is low go for a thyroid scan thyroid scan if it shows a hot nodule then you go for ablation or resection or medical treatment but if the thyroid scan shows a cold or indeterminate module then you can go for an fnac or usd guided biopsy now if you see if the patient has got a normal tsh but still there is a nodule then also you should go for fnac with an fnac if the patient shows if the cytopathology report shows that it is benign or non-diagnostic then you can continue serially monitoring by ultrasonography or if further growth is there or suspicious cytology is there then you can go for a surgery but in case you find that there is a follicular neoplasm or malignancy for that matter malignancy if you're suspecting then there could be a there could be a plan for surgery but if it is a suspicious psychopathological report then go for a thyroid scan again if it shows a hot nodule you can go for ablation resection or medical treatment cold or indeterminate you can go for surgery so this is how you approach a patient with thyroid nodule now few points which i would like to say is that always remember that p3 is an active form okay it's an active hormone whereas t4 is a pro hormone okay so always remember that whenever you check for a thyroid function need not check t3 t4 tsh together you can just go for serial tsh monitoring and also you can go for tsh and ft4 monitoring if they show any discrepancy then only you need to evaluate fd3 for fd3 reports so this is something which you need to remember in a primary thyroid in uh function test another thing that you need to know as i said earlier is that the total t3 and total t4 are always in the bound form so free form is always recommended to be measured then in a case of thyroid toxic causes or graves disease if you check the antibody the anti-tss receptor antibody it is not always practical to go for testing it because test requires it's very expensive it's about four to five thousand rupees so any case of graves disease or thyrotoxicosis you need not check the anti-tss receptor antibody especially in patients who cannot afford it if you go for the clinical symptoms and science if it is present and if tsh is persistently low then directly start the treatment before uh checking the antibody level so these are few things that you need to remember in a thyroid function test thank you so nivedita anything else any questions uh yes and we start taking questions uh so you can start putting in your questions in the comment section um we have a raised hand uh yep dr preem i'm accepting your request you can turn on your audio videos hello hello good evening sir yeah good evening uh yes i have an inquiry like uh my sister is having the tsh value of 7.5 and she is on medication from last five months okay and with that she is also having some symptoms of pcod okay and she is missing the periods like from five to six months [Music] okay so so what can you like help in this suggestion okay uh first and foremost i want to know that tsh was 7.5 before five months after that did you check the tsh level again uh whether it's controlled or not no not yet you have checked it yeah so always remember one thing that once you prescribe a particular medication if tsh is high i always go for rechecking the tsh every one month okay so in one month if the tsh remains controlled then i go for checking it every three months if hypothyroid along with pcod is there and that could be a common cause for irregular menses okay so uh if you correct the thyroid status well and the pcod management is good which includes the insulin resistance as well as weight gain then the period regularity can be improved but of course if still periods remain irregular then you should go for a gynecology consultation just to know if there is any additional cause that is causing the amnoria yes thank you thank you we have a couple of questions that have come in uh we have dr rajasthani who's asked does patients taking exogenous liver thyroxine affect the access function as with anabolic steroids see first and foremost the patients who take anabolic steroids no they have a lot of influence on the central pituitary axis okay exogenous liver thyroxine is usually taken in um you know it depends whether it is injectable or oral okay if you're taking an injectable one then probably the cause would have been something like a mixed edema coma okay so always remember that it is necessary to find out the cause of hypothyroidism whether it is primary or whether it is central if a pituitary axis is involved then anyhow any medication you take there is possibility of getting affected whether yeah so uh first and foremost is that um yeah so if you're taking exogenous liver thyroxine so it depends whether it is oral or iv okay if you're taking iv liver thyroxine then the cause would have been something like a mixed edema coma where there is extremely high tsh and extremely low thyroid hormones in such a case it is important that you find out what is the cause for the hypothyroidism whether it is a central cause or whether it is a primary cause okay so if suppose you have a central cause where pituitary axis is involved and you are already taking anabolic steroids then naturally it is going to affect the pituitary axis but if the primary hypothyroidism is the case then levothyroxine will only affect the thyroid gland per se to increase the thyroid hormones so i feel so it's my opinion where liver thyroxine exogenously if you're giving it depends upon what is the cause whether it is primary or secondary thank you for that explanation um move on to the next question when do we ask for um t3 or rt3 test okay rt3 is basically a reverse t3 where there is an inactive form of t3 test so ideally it is not recommended in any thyroid function test panel because if suppose you are not able to uh let's say check the ft3 level or ft4 levels and both show normal and still you have a suspicion whether there could be a thyroid problem then only you go for rt3 but practically it is not recommended and it is not checked on a routine basis thank you dr ganesh who's asked can any drugs induce thyroid disorders yes there are many drugs which can induce thyroid disorders especially if you are suspecting hypothyroidism then lithium and amiodarone are the most common cause for say inducing hypothyroidism but also there have been but amiodarone is responsible for causing hyper as well as hypothyroidism so like that there are many drugs which are possible but it is important that you find the cause as i said lithium and amiodarone are the most common causes among drugs to cause hypothyroidism uh and we have dr is there a need to do antibody tests in patients with t2dm and hypothyroidism type 2 dm and hypothyroidism so first of all antibody test is to confirm whether hypothyroidism is there if already diagnosed then there is no need but in case but always remember that this antibody test is not for prognosis it is only for diagnosis for confirmating confirming your diagnosis so if you have already diagnosed hypothyroidism then there is no need to confirm it but in case you want to confirm whether there is hypothyroidism or not then you should go for antibody test [Music] if you could just elaborate the treatment a little bit about thyroiditis thyroiditis okay so first and foremost it's important that you know that there are basically many categories of thyroiditis two main common which we see is the subacute thyroiditis which may be caused by infections and another one is the autoimmune thyroiditis if a patient comes with subacute thyroiditis then clinically you can diagnose it if there is a pre-existing viral illness along with that patient will have fever patient will have throat pain the pain will be radiating to the jaw and the neck so this is a classical case of subacute thyroiditis in subacute thyroiditis it's important that you treat the patient with nsaids or painkillers along with that anti-infection or antibiotic agents just to reduce the infection even subacute thyroiditis need not always be viral it could be bacterial also another case is the autoimmune thyroiditis which is basically the lymphocytic infiltration of the thyroid gland along with persistence of antibodies like anti-tbo and anti-thyroglobulin in both these cases both of them which have hyperthyroid features hypothyroid features that took turn by turn patient will have hyperthyroid features for two to six weeks followed by hypothyroid features for two to six weeks then patient may become euthyroid but this duration may not be fixed it may keep wearing so it is important that once you do a tsh and ft4 testing you go for a usg neck once you go for a thyroid scan or ultrasound scan you will know that there is a possibility of thyroiditis or whether there is a nodule or whether it is a primary hypothyroidism case accordingly you will decide what's the next treatment if the patient is having hyperthyroid features then you go for treating it with anti-thyroid drugs if the patient is having hypothyroid features then you go for treating it with thyroid medication so this is the feature this the usually an autoimmune thyroiditis will present with hypothyroidism so you go for treating treating treating it with liver thyroid [Music] so we have dr mandel who is tsh at the bottom serially or fp3 and ft4 is normal uh there is only weight loss uh non-diabetic and psh are in the range of 0.4 to 0.5 on a serial measure and what can be done next one one dsh is between 0.4 and 0.5 then yeah uh there's weight loss non-diabetic and the ft3 and fd4 are normal okay so first and foremost it varies with the reference range every lab has a different reference stage if you look at the normal values of tsh it exists between 0.4 to 4.7 in such a case what i would recommend is that you go for serially monitoring uh the thyroid tsh and ft4 let's say you monitor it after two to three weeks if after two to three week weeks also tsh is consistently low then next step is you can either go for a radioactive iodine uptake thyroid scan with that you can find out whether there's a possibility of or any cause for hyperthyroidism and if that comes positive then go for treating the hyperthyroidism but let's say a patient is having palpitation patient is having heat intolerance along with that patient is having other symptoms of hyperthyroidism then you go for directly treating it with tsh if it is less than 0.005 or ts less than 0.4 thank you are we taken we have [Music] hello yes sir what is the role of steroids in autoimmune thyroiditis any role uh not really sir actually if suppose you're suspecting hashimoto's thyroiditis then the best way is to treat it with thyroid hormones itself steroid if you're describing a particular role it has been proven or scientifically it has shown that only in a case of thyroid crisis or thyrotoxic crisis is where you give steroids or even mixed edema coma to an extent you can give thyroid or you can give steroids steroids are proven beneficial in extreme hypothyroidism and extreme hyperthyroidism and another question was that there was a patient who was waxing and waning between hypo and hyper and when he's consulted when she consulted an endocrinologist that guy had given both pneumococcal have you seen any such patients in one prescription yeah please go ahead please sir yeah so what what i was suggesting is that uh we it is necessary that you do a radioactive iodine uptake scan so with that we will be able to know whether is there a particular cause for that particular condition i don't think both of them together prescribing i i as far as i know there is i don't feel that that's the right way or anybody is yeah right yeah no russian i i don't think there is any other thing was a similar patient was fluctuating between hypo and hyper when we got her usc done that sonography revealed multiple cysts in the thyroid gland so okay is that a normal finding or what so that's what so it if there are multiple systems the thyroid gland know that it all depends upon whether those cysts are functional so let's say if you're finding any particular cyst which is responsible for causing fluctuating thyroid hormones that can be checked by radioactive iodine uptake scan once that is checked if there is anything like that plainly you can go for thyroidectomy i think that is the best solution because i still remember one patient that i had who had a similar condition in such a case what we did is a radioactive iodine uptake scan and if and it turned out to be multiple nodules which are hot as well as cold then you can go for thyroidictor okay thank you thank you so much so we have two questions on antipto so one is what is the role of anti-pto in diagnosis and when is it beneficial and the other one is role of anti-ppo testing in pregnancy and ttpo testing pregnancy okay first and foremost is that anti-tpo has only roll in diagnosis it does not have any role in prognosis so i have seen many prescriptions with state anti-tpu today because thyroid it is a case of hypothyroidism one month later again anti-tpo again one month later anti-tpo and they are checking whether it will reduce or not so it is important that you explain the patient that it is just to diagnose hypothyroidism not to check whether patient is improving or not first question okay second thing is if you have a suspicion of hypothyroidism then you can go for checking anti-tpo antibody it is not very expensive and it can easily be done now coming to a second part of the question where about pregnancy in pregnancy if you have a patient with hypothyroidism you can go for anti-tpo antibody testing but remember that tsh level should always be kept less than 2.5 irrespective of whether patient is pregnant not pregnant planning for treatment for infertility or so on and so forth tsh less than 2.5 is always recommended for a person who's planning pregnancy or a person who is pregnant so let's say a patient is having eu thyroid status antibody is negative but tsh is 4.5 still i would recommend that you start treatment because tsh less than 2.5 is the target recommended by rcog guidelines thank you uh so there's a question by doctor jakarta how to treat hyperthyroidism during pregnancy okay so that's what i said in my presentation earlier if a patient is having hyperthyroidism in pregnancy it's important what is the trimester or what week of pregnancy the patient is in if the patient is below 16 weeks 1 to 16 weeks in such a case do not treat the patient do not do anything because that is a gestational thyroid oxycosis which is a normal phenomenon okay but let's say a patient is beyond 16 weeks and still patient is presenting presenting with low tsh and high thyroid hormones then it's important that even if it is expensive you go for a tsh receptor antibody testing to rule out graves disease if graves disease is present go for treating it so that is the right way of doing it now uh remember that gestational thyrotoxicosis is a phenomenon which is commonly seen because i know that many gynecologists they refer the patient to us for physical fitness for cervical and circulation which happens in the initial first two to three trimesters in such a case if the thyroid hormones are not controlled then you can advise to start the test to get the thyroid hormones in control this is a special case scenario because you have to take the patient for surgery but as for the endocrine lodge's opinion they always recommend do not treat gestational thyroid toxicosis because during a surgery gestational thyrotoxicosis never ever lands up in a thyroid stock so this is a very very important point that we physicians should remember that gestational thyrotoxicosis in literature has not proven any case to cause thyroid storm so even if you don't treat a case of gestational thyrotoxicosis it is perfectly okay [Music] i'm accepting both your requests and turn on your audio and video when the prompts are gone hello good evening sir yeah good evening tell me yes sir us actually wanted to ask that many patients uh we keep on increasing uh thyroxine dose based on the tsh levels but the tsa still not come in the normal range like up to 5.5 they're still like in the 10 16 but we keep on increasing up to 150 micrograms so what to do for that we all guide the patients for compliance we check for compliance we check that they are not taking that their ear not taking anything it is tilting one hour after they're having tablet or gi energy absorption but still sir it's not controlled what to do see first and foremost thyroid it is a misnomer that you know you can just go up to 150 there are patients who take up to 300 350 microgram also there is no particular limit as such okay so even if you increase the thyroid medication there's no harm but of course one thing you need to remember is that even if uh if a hypothyroidism is not getting corrected it's important that you go for a scan or radioactive iodine uptake scan that is very much necessary because just to find out if there is any other cause which may be related to it so that is what you need to do go for a thyroid scan see how is the radioactive iodine uptake and in keep on increasing the dose at one point it has to get controlled even if it doesn't get controlled then you just have to continuously monitor the patient let's say today tsh is 5.2 next month you do you increase the dose up to 200. next month again tsh goes up to 7 increase the dose to 250 next month you will check tsh has come down to let's say 2.2 then you will know that somewhere it lies in between the range always remember this is the only way you can fix a particular dose for thyroid hormones i in one patient of mine it took me nearly one year just to find out what is the correct dose so that period is going to take and you just have to counsel the patient about it and have patience to find out what is the actual dose required to control the hormone level okay and so one more thing so uh actually is my father who is having subacute thyroiditis i have done his ultrasound done and still uh and then uh so what happened he had vital illness before that and so i just uh consulted an endocrinologist he gave him steroids so it is now it has been lapped three months now it has been lapsed but still so he have some pain in the thyroid gland so i'm still continuing with the steroids atmj so what to do now okay so first and foremost did you get a scan done the scan uh iodine uptake scan no so not radioactive iodine uptake we did his ultrasound and it showed thyroiditis and typical features were there okay okay okay fine so first and foremost thing is that you go for a radioactive iodine uptake scan let me tell you it is a very underestimated procedure but iodine uptake scan gives you the correct diagnosis as to how to proceed next okay now in some cases the subacute thyroiditis can persist for a long time but you just have to continue the steroid and that's the right way to do it apart from that you just check is tshft4 how is the level of thyroid hormones it's absolutely normal okay so if thyroid hormones are completely normal just go for a radioactive iodine uptake scan if the scan report shows normal there is no harm in just decreasing the dose and just uh tapering it off but i'm sure if radioactive iodine uptake scan will show something and for how long we can continue steroids for a month some patients take only maybe let's say three to four weeks but some patients take a long period of time but it it all depends upon what the primary cause and primary condition is okay so it is important that you go for a scan then only we can decide the next step okay so answer last question so actually a patient came to me she had complained of painful swallowing only painful swellings in six months and she got her ultrasound neck done there was uh there was a colloid goiter in the ultrasound then i got her thyroid profile done and tsh was 0.14 and t3t was normal then i got her fnac done and affinity revealed benign thyroid disease and since only she has complained of painful swallowing i started steroids now but still i'm not able to understand what's the diagnosis and what to do first and foremost uh painful swallowing is there second thing you check that there is a thyroid cyst or sorry a colloidal kind of scenario if colloidal is the cause for causing dysphagia then directly go for the removal thyroidectomy is the final answer but let me tell you one thing that's one thing that you've forgotten if a patient is having dysphagia and apart from thyroid you have to check whether there's another course go for ogd scope and see if there is another cause for it if ogd scorpio still remains clear then it is very evident that thyroid is the cause directly go for thyroidectomy because patient is clinically symptomatic but even if thyroid gland is not palpable also then can also then also it can cause dysphagia see that is what i'm trying to tell you it is not always thyroid gland does not enlarge in a particular direction always okay because it is as you know it's an x-shaped one so any one particular area can get enlarged and that particular area may not be palpable but internally it may be causing compression on the esophagus you never know so it is always important that you rule out another cause if that is not there and you confirm thyroid is a cause go for thyrotic tonic ogt means upper gi endoscopy right yeah upper gi scope yes right sir okay so thank you thanks a lot sir hello hello hello yes yes yeah good evening uh sir with respect uh uh so with respect to the previous question they asked in case of non-palpable thyroid swelling and the patient comes to us with the painful pain during the swallowing uh ultrasound shows that if the ultrasound shows similar scenario like collared water or small sister and the clinical it is not multiple and the patient may be having a hypothyroidism so uh even if you do a purging endoscopy uh we if we may not if there are no other causes for our other cause for dysphagia uh is it ideal to undergo a thyroidectomy or should we undergo another model if you like ct or anything okay one minute one minute first and foremost first and foremost she mentioned that thyroid hormones are normal okay but in case if the thyroid hormones are low then obviously you have to start thyroid medications once you start thyroid medications naturally there are possibility that the goiter size can increase it can reduce so once it reduces the compression will naturally reduce but if that is not the case then you can just to just find out if there is any other cause if any other cause is not there then naturally you just have to go for the procedure sir okay so one more question sir so uh what to do if uh if the patient comes to us and tsh is high uh t3 patient is hypothyroid and uh we don't have any option of radioactive iodine uptake uh like patient is not affordable or service is not available in that is interior so is it ideal or is it rational to directly start uh liver thorax in hormone medication or how effective it is just see i'll tell you something uh yeah so if suppose your thyroid hormones are low and symptomatically you feel that there is possibility of hypothyroidism directly you can start there is no need for a conformity test everybody as for the clinical flow chart if as for the guidelines what is given they always recommend anti-tpu antibody but it's not always possible in an indian scenario so naturally if you have symptoms and thyroid hormones are low it's better you start the treatment and then you observe after one month as to how much is the improvement and how much is the thyroid okay thank you so much sir thank you doctor there uh so we'll give a couple of questions more um so we have uh dr abhinash who's asked a lady who's on thyroid medications came with a tsh report of 12 but t3 and t4 were normal so what do we advise her should we continue or discontinue with the medications no no even if uh so it depends so first and foremost if suppose a patient is pregnant then it's important that you serially monitor the ft4 levels if ft4 levels continue to remain normal then you continue with the same dose medication but otherwise in a normal scenario if tsh is consistently high you go on increasing the dose till the time the tsh level comes to normal it's important that you check the free levels okay the total levels cannot be checked it's important that free levels are checked and then you continue the medication and see when tsh comes back to the normal page thank you uh and and so we have talked to samyang who's asked tsh is between 30 and 35 is underweight and not able to gain weight so i mean what would be the treatment for that yeah so this is something which i said that there could be a mixed picture where there is hypothyroidism but clinically patient source shows hyperthyroidism so this is a case where you can go for a usg neck or a radioactive iodine uptake scan and see whether there is any possibility of autoimmune thyroiditis or whether there is a hot and a cold nodule and then accordingly you can decipher the tree okay thank you we have dr bharti who's asked uh there's a well-defined cystic module uh measuring 2.4 uh by 1.7 centimeters in the right lobe uh there's no solid component or no solid component or vascular scene a few smaller nodules about five to six mm seen on both lobes uh two to three in number does this need a follow-up scan of course definitely it does require a follow-up scan just to check whether there is any uh hot nodule or a cold nodule and always remember that if a patient is having multiple nodules then it is not necessary that if it is non-functional today it will be non-functional three months later it may not be it will always it can fluctuate because thyroid hormones may uh the nodules may take up the function to release the thyroid hormones so it's important that every three to six months you repeat the scan to check whether there is any possibility of autofollows if a patient is controlled on l-toxin long term and recently started on steroids for lung hypersensitivity pneumonitis do we alter the dose of hydroxyl okay so first and foremost it's important that you continue to monitor the tsh and fd4 levels if the thyroid hormones are increased or decreased for say you can monitor you can change the dose repeatedly but it's not just because a patient is taking steroid it's not necessary that you reduce the dose or increase the dose it's important that you seriously monitor the tsh and fd4 levels thank you thank you i'll just check the questions once again i think you mostly answered all the questions either directly or as an answer to another question uh so uh dr jatendra has asked what is the role of aspiration as treatment for thyroid cyst role of aspiration so first and foremost it's important that uh whenever you get a cyst or a nodule it's important that you do fnac or biopsy as i showed in the slide before once you do that it's important you go for cytopathology report and then you can decide what to do next okay so that is a very uh you know depends on what comes the what the result comes out to be so then only you can decide what's the next procedure okay and uh follow-up question since we are talking about electroxen what is the dose that it is that we start with foreign if always remember that when a patient comes let's say a tsh level is 40 and the patient weighs let's say about 50 kg so do not go start electroxen depending upon the tsh value it's important that you start electroxen depending upon the body weight so electroxen should be started at a dose of 1 to 1.5 milligram per kg body weight but in case of a patient is pregnant in case of a patient is pregnant then you start at a dose of 0.8 to 1 milligram per kg body weight if the patient is elderly then you further reduce it as 0.5 to 1 milligram per kg body weight so that is something that you need to remember that it depends upon the body weight but again you increase the dose depending upon the function of the thyroid gland thank you for that um i think most of the questions have been uh answered if there are any questions that we have missed out uh we'll just send it uh to sir and then we'll have them answered for you um okay there's one by doctor who's asked dsr is fluctuating due to chemotherapy uh how would we treat this see everything comes with the same answer that you go for a thyroid scan or a radioactive iodine uptake scan remember if a patient is on chemo there is high possibility that could be metastasis or there is possibility that the thyroid gland could also have some kind of malignant deposition so that could be the cause for the fluctuating thyroid hormones in case you don't find anything like that then you just go for reductive iodine uptake scan or thyroid scan and then you decide what is the next stream so i i can understand why majority of the questions are coming like this because radioactive iodine uptake scan is not available everywhere first problem second problem is once you check the thyroid hormones after that apart from starting treatment we ourselves don't know how to proceed next so that is where we directly refer to endocrinologist and then decide but remember one thing the endocrinologist is also going to order the same thing so it's important that once you check the thyroid hormones if you have any doubt you can go for either antibody testing or go for a radioactive iodine uptake thyroid scan and then you can decide what is the next step thank you sir um i think we finished all the questions uh i think we can uh close the session here and uh thank you so much for coming on netflix once again and we look forward to your next session thank you so much and have a good evening thank you so much

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Dr. Nagesh Bodewar & 1846 others

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft Hospital & AR Medical Center, Kodungallur, Cochin | General Physician MIT Mission Hospital, Kodungallur, Cochin Senior Resident at Dept of Medicine, Al Azha...

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft H...

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