On these “Gold Standard Internal Medicine Facts” pages you will find Free:
- USMLE Audio Review files from our “Gold Standard USMLE Reviews”
- Transcriptions of those files
- And videos (as they become available)
The idea is that you can review for the USMLE online by:
- Listening to the Audio
- Following along with the transcription
- Or by watching the video (if available)
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Let’s start our USMLE Review with Hypothyroidism and Hyperthyroidism from the Gold Standard USMLE Foundations of Medicine Audio Review program.
Play USMLE Audio MP3 10 14 Pituitary Myxedema vs. Primary Myxedema Below
Begin 10 14 Pituitary Myxedema vs. Primary Myxedema Transcription
It’s important to differentiate primary myxedema from pituitary myxedema for which glucocorticoid replacement is essential.
What are a couple of clues in the patient history as to the presence of pituitary myxedema?
- History of amenorrhea or impotence.
And a physical finding indicative of pituitary myxedema?
- Scanty, pubic or axillary hair.
What about serum cholesterol and TSH levels?
- Serum cholesterol is normal and TSH normal or low in a pituitary myxedema patient.
CT scan or MRI may reveal which significant finding?
- An enlarged sella turcica.
Student doctor please pause the tape and summarize the differentiation between primary and pituitary myxedema.
- It’s important to differentiate primary myxedema from pituitary myxedema as the later requires glucocorticoid replacement. Clues as to the presence of pituitary myxedema include a history amenorrhea or impotence, scanty, pubic or axillary hair, normal serum cholesterol and normal to low TSH levels and an enlarged sella turcica on CT scan or MRI.
A further complication with hypothyroidism is when myxedema is associated with heart disease. In a past, treatment of patients with myxedema and heart disease, especially coronary artery disease was difficult because the prevalent therapy was frequently associated with exacerbation of angina, heart failure, or myocardial infarction.
What was that therapy?
- Levothyroxine replacement therapy.
Patients with myxedema and coronary artery disease now have two surgical alternatives to Levothyroxine replacement. So they can first be treated surgically then Thyroxine replacement therapy is better tolerated.
What are the two surgical therapies?
- Coronary angioplasty and coronary artery bypass surgery.
One final complication we’ll look at is hypothyroidism and neuropsychiatric disease. As we’ve said hypothyroidism is often associated with depression which can be quite severe. More rarely, myxedematous patients may become confused, paranoid or even manic.
What is an informal term for this condition?
- Myxedema madness.
What is a good way to identify myxedema madness candidates on hospital admission?
- By screening psychiatric admissions with FT4 and TSH.
They will often respond to Levothyroxine therapy alone or in conjunction with psychotrophic agents.What has given rise to the hypothesis that the addition of T3 or T4 to psychotherapeutic regimens for depressed patients may be helpful even in cases without any demonstrable thyroid disease? Please pause the tape.
- The effectiveness of Levothyroxine therapy in depressed hypothyroid patients led to the idea that thyroid hormones might be beneficial for depressed patients in general, with or without thyroid abnormality. Further research will be necessary before this becomes standard practice.
Student doctor please pause the tape and summarize neuropsychiatric disease as a complication of hypothyroidism.
- The depression sometimes associated with hypothyroidism can be quite severe, sometimes developing into myxedema madness, characterized by confusion, paranoia, and mania. Screening psychiatric admissions with FT4 and TSH tests is a good way to identify these patients who often respond to Levothyroxine therapy alone or in conjunction with psychothrophic agents. The effectiveness of Levothyroxine in that patient population has given rise to that concept that patients suffering from depressive symptoms may benefit from T3or T4 hormone therapy even without the presence of thyroid illness. Further research will be needed before this will become standard practice.
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