DIRECTED SELF LEARNING (DSL) PACKAGE

KULLIYYAH OF MEDICINE & HEALTH

SCIENCES
Topic

Thyroid Function Tests

Course/Course Code
Year/Semester/Session
Date

Endocrine System/PPP 10402

1/ 1/2014-2015
24th September, 2014

Time

5.00pm06.00pm

Students Name/ ID
Lecturer Name

DR. NURUDDIN MOHAMMED NUR

At the end of this DSL package, the students will be able to:
1. describe the thyroid function tests.

Learning
outcomes

2. discuss the clinical use of thyroid function tests.

3. interpret the results of thyroid function tests.

1. Drew Provan, Andrew Krentz. Oxford Handbook of Clinical and

Laboratory Investigation. Oxford University Press. 2002.
2. Steven L. Jones. Clinical Laboratory Pearls. Lippincott, Williams and
Wilkins.2001.
References

3. Joel D. Hubbard. A Concise Review of Clinical Laboratory Science. 2 nd

edition. Lippincott, Williams and Wilkins. 2010
4. Dan L. Longo, MD, et al. Harrisons Principle of Internal Medicine. 18 th
edition. McGrawhill.2012.
5. American Thyroid Association www.thyroid.org. June 4, 2012

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ACTIVITIES
LO 1

describe thyroid function tests.

The thyroid gland produces thyroid hormones triiodothyronine (T3), thyroxine (T4), and
calcitonin. T4 is a prohormone produced by the follicular cells of the thyroid gland and maybe
metabolized into the more active T3 in peripheral tissues. Almost all of the circulating T3 and T4 are
bound to proteins such as thyroxine-binding globulin (TBG), thyroxine binding prealbumin (TBPA)
and albumin. Only about 0.01% of T4 is unbound or FREE (which is the biologically active form).
Question 1. Name the hormones that govern the production and secretion of T3 and T4.
__________________, ____________________, _______________________.
Question 2. Name the gland __________________ and part of the brain ___________________ that
secretes the hormones in Question 1.
The thyroid function tests include the following assay to assess the function and status of the
thyroid:

A. Thyroid Stimulating Hormone (TSH)

o This is a good indicator of thyroid function and is the initial hormone to be
tested in suspected thyroid diseases. TSH hormone assay however cannot be
used in patients with pituitary diseases as TSH is produced by the pituitary
gland.
o A high TSH level indicates that the thyroid gland is failing because of a problem that
is directly affecting the thyroid (primary hypothyroidism). The opposite situation, in
which the TSH level is low, usually indicates that the person has an overactive
thyroid that is producing too much thyroid hormone (hyperthyroidism). In most
healthy individuals, a normal TSH value means that the thyroid is functioning
normally.

B. Total T4/Total Thyroxine/Serum Thyroxine

o This test measures the total amount of circulating thyroxine in your blood. A
high value can indicate hyperthyroidism whereas a low value can indicate
hypothyroidism. Total T4 levels can be elevated due to pregnancy, and other
high estrogen states, including use of estrogen replacement or birth control
pills. Because the free levels of T4 represent immediately available hormone,
free T4 is thought to better reflect the patient's hormonal status than total T4.
C. FreeT4 (FT4)
o Individuals who have hyperthyroidism will have an elevated FT4, whereas
patients with hypothyroidism will have a low level of FT4. Combining the
TSH test with the FT4 accurately determines how the thyroid gland is
functioning. The finding of an elevated TSH and low FT4 indicates primary
hypothyroidism due to disease in the thyroid gland. A low TSH and low FT4
indicate hypothyroidism due to a problem involving the pituitary gland. A low
TSH with an elevated FT4 is found in individuals who have hyperthyroidism.

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D. T3
o T3 tests are often useful to diagnosis hyperthyroidism or to determine the
severity of the hyperthyroidism. Patients who are hyperthyroid will have an
elevated T3 level. In some individuals with a low TSH, only the T3 is elevated
and the FT4 is normal. T3 testing rarely is helpful in the hypothyroid patient,
since it is the last test to become abnormal. Patients can be severely
hypothyroid with a high TSH and low FT4, but have a normal T3.
E. Free T3 / Free Triiodothyronine
o Free T3 measures the free, unbound levels of triiodothyronine in your
bloodstream. Free T3 is considered more accurate than Total T3. Free T3 is
typically elevated in hyperthyroidism, and lowered in hypothyroidism.
Question 3. Describe how a thyroid function test for TSH, T3 and T4 is done. What is the specimen
needed for the test? _________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Other tests used to assess thyroid function include:

A. Thyroid antibody tests
o The immune system of the body normally protects us from foreign invaders
such as bacteria and viruses by destroying these invaders with substances
called antibodies produced by blood cells known as lymphocytes. In many
patients with hypothyroidism or hyperthyroidism, lymphocytes make
antibodies against their thyroid that either stimulate or damage the gland. Two
common antibodies that cause thyroid problems are directed against thyroid
cell proteins: thyroid peroxidase and thyroglobulin. Measuring levels of
thyroid antibodies may help diagnose the cause of the thyroid problems.
B. Radioactive iodine uptake
o Because T4 contains much iodine, the thyroid gland must pull a large
amount of iodine out from the blood stream in order for the gland to make
an appropriate amount of T4. The thyroid has developed a very active
mechanism for doing this. By measuring the amount of radioactivity that
is taken up by the thyroid gland (radioactive iodine uptake, RAIU), one
may determine whether the gland is functioning normally.
Question 4. Describe the procedure of the Radioactive Iodine Uptake test.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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_____________________________________________________________________
_____________________________________________________________________
C. Ultrasound examination
o Painless method that uses sound waves to create images of the inside of the
body. The transducer gives off sound waves. The sound waves go through the
body and bounce off the area being studied (in this case, the thyroid gland). A
computer looks at the pattern that the sound waves create when bouncing
back, and creates an image. Thyroid UTZ is usually done when there is an
abnormal growth in the thyroid gland. The UTZ can differentiate between a
cyst and a solid tumor. In addition to detecting thyroid nodules, ultrasound is
useful for monitoring nodule size and for the aspiration of nodules or cystic
lesions. Ultrasonography is also used in the evaluation of recurrent thyroid
cancer, including possible spread to cervical lymph nodes.
Question 5. Based on sonographic characteristics, describe the differences between a
cystic
thyroid
lesions
and
a
solid
thyroid
lesion.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

LO 2

discuss the clinical use of thyroid function tests.

A thyroid function test panel maybe requested for the following patients:
1. Patient suspected to have hyperthyroidism.
Increased thyroid hormone in the bloodstream causes hyperthyroidism, which
results in increased metabolic rate, weight loss, sweating, tachycardia, palpitation,
and high blood pressure, among other symptoms. The laboratory evaluation of
hyperthyroidism in the initial evaluation reveals elevated thyroid hormone serum
levels and decreased serum TSH.
2. Patient suspected to have hypothyroidism.
Decreased thyroid hormone causes hypothyroidism which leads to fatigue,
weight gain, cold intolerance, and related symptoms. In the laboratory evaluation
of hypothyroidism, the earliest abnormality is increased TSH, followed by
decreased serum levels of thyroid hormones.
3. Patient taking either thyroid suppression or thyroid hormone replacement
therapy. This is to monitor the effectiveness of the therapy in the patient.
4. Newborn babies before they leave the hospital.

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Question 6. What is the disease entity that is being screened in newborn babies in
which a thyroid function test is used?
__________________________________________________
What specific thyroid hormone is being tested in these newborns?
______________________________
Hyperthyroidism and hypothyroidism are most often caused by autoimmune diseases.
Normally, the immune system produces antibodies that defend the body against foreign
substances such as bacteria. In autoimmune diseases, however, the immune system produces
"autoantibodies" that attack the body's own healthy cells and tissues-in this case, the thyroid.
Graves' disease is the most common cause of autoimmune hyperthyroidism.
Laboratory results for Graves disease indicate increased T3, T4 and decreased or normal
TSH. Hashimoto's disease is the most common cause of autoimmune hypothyroidism. Both
Graves' disease and Hashimoto's disease are due to an immune attack on the thyroid. In
Graves' disease, the attacking antibodies stimulate thyroid hormone production.
Question 7. List factors that will give rise to falsely elevated T3 and T4 test result.
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Thyroid Antibody test is an important test in the laboratory investigation of
hypothyroidism or hyperthyroidism. For example, positive anti-thyroid peroxidase and/or
anti-thyroglobulin antibodies in a patient with hypothyroidism make a diagnosis of
Hashimotos thyroiditis. If the antibodies are positive in a hyperthyroid patient, the most
likely diagnosis is autoimmune thyroid disease.
A very high RAIU is seen in individuals whose thyroid gland is overactive
(hyperthyroidism), while a low RAIU is seen when the thyroid gland is underactive
(hypothyroidism).
LO 3

Interpret the results of thyroid function tests.

Because TSH levels change dynamically in response to alterations of T4 and T 3, a

logical approach to thyroid testing is to first determine whether TSH is suppressed, normal, or
elevated.
The finding of an abnormal TSH level must be followed by measurements of
circulating thyroid hormone levels to confirm the diagnosis of hyperthyroidism (suppressed
TSH) or hypothyroidism (elevated TSH).
Clinical Application:

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1. D.M., a 39 year old female presented with palpitation, tremors, sweating, insomnia, and
weight loss. You are suspecting a thyroid problem. In her medical chart though, the previous
houseman on duty noted the patient is due for work-up for a suspected pituitary adenoma. Of
the blood thyroid function tests, which test can you NOT request for this patient and why?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

2. P.W. a 31 year old female presented with hoarse voice, constipation, weight gain,
sluggishness, and muscle weakness. You requested for thyroid function test. The
results are as follows:
Test

Patient Result Reference Range

TSH

6.03

0.344.25 mIU/L

FT4

9 16 pmol/L

T3

0.9

1.22.1 nmol/L

What is the most likely diagnosis?: _______________________________________

3. D.G., a 28 year old female complained of palpitation, hand tremor, and difficulty of
sleeping. A TSH assay result: 0.22 mIU/L (N.V. 0.34 4.25 mIU/L). What is your
next step? ________________________________________________________
If this patient has hyperthyroidism. What is the expected lab results for T3 or T4
(increased or decreased)? __________________________
4. A 46 year old female presented with an anterior neck mass of 3 years duration. You
noticed that her eyes are unusually bulging. She complains of palpitations, increased
sweating and hand tremors. On physical examination, you noted that the patient had
pretibial myxedema. The lab results are as follows:
Test

Patient Result Reference Range

TSH

0.40

0.34 4.25 mIU/L

FT4

27

9.0 16 pmol/L

What is the most likely diagnosis? ________________________________________

5. A Radioactive Iodine Uptake test was done on a patient with goiter. The result after 24
hours is: 36% (Ref.range : 8% - 25%).
What is the diagnosis? __________________________________________________

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Nam
e
Date

Prepared by

Checked by

Dr. Nuruddin
Mohammed Nur

Ms Izzati Ismail

21/09/2014

Approved by