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Serum levels of free thyroid hormones should be used when interpreting an abnormal TSH level, especially in the acute and inpatient settings. A low TSH level is not always the result of suppression by elevations in circulating thyroid hormones. A low TSH level in the setting of normal levels of free thyroid hormones should always be reassessed in 4 to 6 weeks before making a diagnosis. Natural history of subclinical hyperthyroidism in elderly patients with TSH between 0.
A 34-year-old woman presents to the outpatient endocrinology clinic 4 months postpartum. She says that 2 months ago she developed palpitations, heat intolerance, and difficulty sleeping. On follow-up testing 6 weeks later, her TSH level had risen, but it was still low at 0. L, and her free T4 level was now low at 0. She was referred to an endocrinologist for further management. How should this patient be further evaluated and managed?
A low serum TSH level, ie, less than 0. In diagnosing the correct cause, patience is a virtue. The levels of free T4 and free T3 should be used, not total levels, when interpreting an abnormal TSH value. This especially applies in the acute and inpatient settings, in which many patients are malnourished and consequently have low serum levels of thyroid-binding globulin and albumin. In this situation, total T4 and T3 levels may be low and not accurately represent a patient’s true thyroid status. However, depending on the analytical method, even measurements of the free hormones may be affected by the protein changes that occur during severe illness or pregnancy.