CASE INFORMATION

Case ID: HYPOTH-004
Case Name: Sarah Williams
Age: 45
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T85 (Hypothyroidism/myxoedema)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates effectively to explain chronic disease management 1.3 Uses patient-centred language to discuss symptoms and treatment adherence
2. Clinical Information Gathering and Interpretation	2.1 Conducts a comprehensive history and examination to identify hypothyroidism 2.3 Orders and interprets thyroid function tests appropriately
3. Diagnosis, Decision-Making and Reasoning	3.1 Makes an accurate diagnosis of hypothyroidism based on clinical and biochemical findings 3.3 Differentiates primary hypothyroidism from secondary causes
4. Clinical Management and Therapeutic Reasoning	4.1 Provides appropriate levothyroxine treatment and follow-up plan 4.4 Adjusts treatment based on TSH and T4 levels
5. Preventive and Population Health	5.1 Provides lifestyle and dietary advice for patients with hypothyroidism
6. Professionalism	6.2 Ensures clear communication about the importance of adherence to thyroid hormone replacement
7. General Practice Systems and Regulatory Requirements	7.1 Documents and monitors thyroid function tests per guidelines
8. Procedural Skills	8.2 Recognises indications for further investigations such as thyroid ultrasound
9. Managing Uncertainty	9.1 Identifies when referral to an endocrinologist is warranted
10. Identifying and Managing the Patient with Significant Illness	10.2 Recognises and manages complications such as myxoedema coma

CASE FEATURES

Middle-aged woman presenting with fatigue, weight gain, and cold intolerance
Features suggestive of hypothyroidism on examination
Requires thyroid function testing and appropriate levothyroxine initiation
Management of chronic disease, including medication adherence and follow-up
Differentiating primary from secondary hypothyroidism

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Williams
Age: 45
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

Gestational hypothyroidism (resolved post-pregnancy)
Family history of Hashimoto’s thyroiditis (mother)

Social History

Works as an accountant, sedentary lifestyle
Reports low energy levels, low mood, and difficulty concentrating
No smoking or alcohol use

Family History

Mother: Hypothyroidism (Hashimoto’s)
Father: Hypertension and Type 2 Diabetes

Symptoms

Fatigue, weight gain (5 kg over 6 months)
Cold intolerance, dry skin, hair thinning
Constipation and mild depressive symptoms
No palpitations or heat intolerance

Vaccination and Preventative Activities

Up to date with cervical screening and immunisations

SCENARIO

Sarah Williams, a 45-year-old accountant, presents with fatigue, weight gain, and cold intolerance over the past 6 months. She has noticed dry skin, hair thinning, and constipation. She denies palpitations, sweating, or diarrhoea.

She has a history of gestational hypothyroidism, but postnatal thyroid function tests normalised, and she was not prescribed long-term thyroid replacement therapy.

Her family history is significant for Hashimoto’s thyroiditis, raising suspicion of autoimmune hypothyroidism. She has been struggling with low mood and difficulty concentrating, which she initially attributed to work stress but is now more persistent.

On examination:

EXAMINATION FINDINGS

General Appearance:

Puffy face with periorbital oedema
Dry, coarse skin
Sparse outer eyebrows (Queen Anne’s sign)

Vital Signs:

Temperature: 35.8°C
Blood Pressure: 130/85 mmHg
Heart Rate: 55 bpm
Respiratory Rate: 14 breaths per minute
BMI: 28 (Overweight)

Neck Examination:

Mildly enlarged thyroid gland (diffuse, non-tender)

Neurological Examination:

Delayed relaxation of deep tendon reflexes (Achilles reflex)

INVESTIGATION FINDINGS

TSH: 9.8 mIU/L (0.5 – 4.5) ↑
Free T4: 8 pmol/L (10 – 20) ↓
TPO Antibodies: Positive
HbA1c: 5.6% (Normal)
Lipids: Total cholesterol 6.2 mmol/L, LDL 4.0 mmol/L (Elevated)

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your assessment of Sarah’s condition based on history and investigations?

Prompt: What features suggest primary hypothyroidism?
Prompt: What additional history would you ask?

Q2. How would you manage Sarah’s hypothyroidism?

Prompt: What medication would you prescribe and how would you monitor response?
Prompt: What patient education is important regarding levothyroxine therapy?

Q3. How would you differentiate primary hypothyroidism from secondary causes?

Prompt: What tests would help confirm the diagnosis?
Prompt: When would you suspect secondary hypothyroidism?

Q4. What complications are associated with untreated hypothyroidism, and how would you manage them?

Prompt: What are the features of myxoedema coma?
Prompt: When would hospital referral be required?

Q5. What lifestyle and preventive health advice would you provide Sarah?

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your assessment of Sarah’s condition based on history and investigations?

Prompt: What features suggest primary hypothyroidism?
Prompt: What additional history would you ask?

Q2. How would you manage Sarah’s hypothyroidism?

Prompt: What medication would you prescribe and how would you monitor response?
Prompt: What patient education is important regarding levothyroxine therapy?

Q3. How would you differentiate primary hypothyroidism from secondary causes?

Prompt: What tests would help confirm the diagnosis?
Prompt: When would you suspect secondary hypothyroidism?

Q4. What complications are associated with untreated hypothyroidism, and how would you manage them?

Prompt: What are the features of myxoedema coma?
Prompt: When would hospital referral be required?

Q5. What lifestyle and preventive health advice would you provide Sarah?

Prompt: How can she optimise her overall health with hypothyroidism?
Prompt: What cardiovascular risk factors should be addressed?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your assessment of Sarah’s condition based on history and investigations?

Sarah presents with fatigue, weight gain, cold intolerance, dry skin, and hair thinning, which are classic symptoms of hypothyroidism. Her history of gestational hypothyroidism and family history of Hashimoto’s thyroiditis raise suspicion of autoimmune hypothyroidism.

1. Diagnosis: Primary Hypothyroidism

Her TSH is elevated (9.8 mIU/L) with low free T4 (8 pmol/L), and TPO antibodies are positive, confirming autoimmune primary hypothyroidism.

2. Additional History to Clarify:

Fatigue impact on daily activities (work, mood, exercise tolerance)
Menstrual irregularities (possible association with hypothyroidism)
Cognitive symptoms (memory, concentration, mood changes)
Cardiovascular risk factors (hyperlipidaemia and metabolic risks)
Medication use (e.g., lithium, amiodarone) or iodine exposure

This information confirms chronic autoimmune hypothyroidism, requiring levothyroxine replacement therapy.

Q2: How would you manage Sarah’s hypothyroidism?

1. Initiation of Levothyroxine Therapy

Start levothyroxine 50 mcg daily, titrated based on TSH levels every 6-8 weeks.
Monitor symptoms and adjust dose accordingly (target TSH: 0.5-2.5 mIU/L).
Take on an empty stomach (30-60 minutes before breakfast).

2. Patient Education

Consistency is key – missed doses can impact treatment efficacy.
Avoid interactions – calcium, iron, and antacids interfere with absorption.
Symptoms improve gradually – energy levels may take weeks to normalise.

3. Follow-Up Plan

Repeat TSH/T4 in 6-8 weeks to assess adequacy of dosing.
Monitor for over-replacement (palpitations, weight loss, anxiety, sweating).
Annual thyroid function tests once stable.

This approach ensures effective symptom control and prevention of complications.

Q3: How would you differentiate primary hypothyroidism from secondary causes?

1. Primary vs Secondary Hypothyroidism

Primary (thyroid origin) → High TSH, Low T4 (seen in Sarah’s case).
Secondary (pituitary/hypothalamic cause) → Low TSH, Low T4 (suggests central hypothyroidism).

2. When to Suspect Secondary Hypothyroidism?

No goitre or thyroid autoantibodies.
History of pituitary disease or head trauma.
Other pituitary hormone deficiencies (low ACTH, FSH/LH, GH).

3. Investigations to Confirm

Serum TSH and free T4 (already done).
Morning cortisol and ACTH (rule out adrenal insufficiency).
MRI pituitary (if central hypothyroidism suspected).

Sarah’s elevated TSH and positive TPO antibodies confirm primary autoimmune hypothyroidism.

Q4: What complications are associated with untreated hypothyroidism, and how would you manage them?

1. Complications of Untreated Hypothyroidism

Cardiovascular disease (hyperlipidaemia, hypertension, atherosclerosis).
Infertility and pregnancy complications (miscarriage, pre-eclampsia).
Neurological symptoms (cognitive impairment, depression).
Myxoedema coma (severe untreated hypothyroidism).

2. Recognition and Management of Myxoedema Coma

Red Flags: Hypothermia, altered mental state, bradycardia, hypotension.
Emergency Management:
- IV levothyroxine + IV hydrocortisone (to cover possible adrenal insufficiency).
- ICU admission for supportive care (fluids, warming, ventilation if needed).

Timely diagnosis and treatment prevent severe complications.

Q5: What lifestyle and preventive health advice would you provide Sarah?

1. Lifestyle Modifications

Balanced diet (adequate iodine intake but avoid excess in autoimmune thyroiditis).
Regular physical activity (helps manage weight gain).
Good sleep hygiene (reduces fatigue and supports cognitive function).

2. Cardiovascular Risk Management

Monitor and manage hyperlipidaemia (lifestyle + statins if required).
Regular BP checks (thyroid disease can affect BP regulation).

3. Long-Term Monitoring

Annual thyroid function tests once stable.
Preconception advice – optimise TSH before pregnancy.

Holistic care ensures optimal health outcomes beyond thyroid hormone replacement.

SUMMARY OF A COMPETENT ANSWER

Accurately diagnoses autoimmune hypothyroidism based on history and investigations.
Initiates levothyroxine therapy appropriately and educates on adherence.
Differentiates primary from secondary hypothyroidism using clinical and biochemical features.
Recognises complications, including cardiovascular risks and myxoedema coma.
Provides lifestyle and preventive health advice to optimise long-term outcomes.

PITFALLS

Failing to differentiate primary vs secondary hypothyroidism.
Inadequate levothyroxine dosing or lack of regular monitoring.
Not counselling on medication adherence and dietary interactions.
Missing associated conditions like hyperlipidaemia and cardiovascular risk.
Delaying emergency management of myxoedema coma.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively to explain chronic disease management.
1.3 Uses patient-centred language to discuss symptoms and treatment adherence.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a comprehensive history and examination to identify hypothyroidism.
2.3 Orders and interprets thyroid function tests appropriately.

3. Diagnosis, Decision-Making and Reasoning

3.1 Makes an accurate diagnosis of hypothyroidism based on clinical and biochemical findings.
3.3 Differentiates primary hypothyroidism from secondary causes.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate levothyroxine treatment and follow-up plan.
4.4 Adjusts treatment based on TSH and T4 levels.

5. Preventive and Population Health

5.1 Provides lifestyle and dietary advice for patients with hypothyroidism.

6. Professionalism

6.2 Ensures clear communication about the importance of adherence to thyroid hormone replacement.

7. General Practice Systems and Regulatory Requirements

7.1 Documents and monitors thyroid function tests per guidelines.

8. Procedural Skills

8.2 Recognises indications for further investigations such as thyroid ultrasound.

9. Managing Uncertainty

9.1 Identifies when referral to an endocrinologist is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.2 Recognises and manages complications such as myxoedema coma.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD