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T4 elevated, free T4 normal, T3 elevated, thyroid stimulating hormone (TSH) normal
9%
1/11
T4 elevated, free T4 elevated, T3 elevated, TSH elevated
0%
0/11
T4 elevated, free T4 elevated, T3 elevated, TSH decreased
91%
10/11
T4 decreased, free T4 decreased, T3 decreased, TSH decreased
T4 normal, free T4 normal, T3 normal, TSH elevated
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With a symmetrically enlarged thyroid gland, signs of hyperthyroidism, and an autoimmune history, the patient most likely has Graves' disease. The thyroid studies would demonstrate elevated levels of T4, free T4, and T3 with a decrease in TSH. Graves' disease is an autoimmune disorder caused by thyroid stimulating immunoglobulins binding to TSH receptors producing thyroid growth and excess hormone production (hence the elevated T4, free T4, and T3). The resulting hyperthyroidism manifestations include heat intolerance, weight loss, diarrhea, hyper-reflexia, tachycardia, and palpitations. Graves' disease is also associated with autoimmune disorders such as pernicious anemia, vitiligo, systemic lupus erythematosus, and type 1 diabetes, among others, which suggests an autoimmune source of hyperthyroidism. TSH levels are decreased in these patients due to hypothalamic/pituitary feedback inhibition. Reed et al. explain the diagnosis and treatment of hyperthyroidism. The initial diagnostic test is a thyroid function panel followed by radionucleotide uptake scans if the diagnosis remains unclear. Graves' disease is the most common cause of hyperthyroidism in the United States and treatment includes radioactive iodine (preferred), antithyroid drugs, or a thyroidectomy. Other causes include thyroiditis, toxic multinodular goiter, and toxic adenomas. Braverman explains the expected serology in thyrotoxic states which reflect a hyperthyroid state found in severe cases of Grave's disease. T4, free T4, and T3 are expected to be increased on thyroid function studies. TSH is expected to be decreased in all hyperthyroid states except those with a TSH-secreting pituitary tumor or selective pituitary resistance to thyroid hormone (both quite rare compared to Grave's disease). Incorrect Answers: Answer 1: This would reflect a patient on birth control pills secondary to estrogen effects increasing thyroid binding globulins, not Graves' disease. Answer 2: This would reflect hyperthyroidism secondary to a pituitary tumor not Graves' Disease. Answer 4: This would reflect a hypothyroid state not a hyperthyroid state. Answer 5: This would reflect a subclinical thyroid gland insensitivity to TSH, not Graves' Disease.
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