ACD 10/20/14

YOGITA ROCHLANI

SIMULATED CASE

CHIEF COMPLAINT

30 Y.O. WOMAN PRESENTS TO THE ER WITH INCREASING ANXIETY,

PALPITATIONS, TREMORS, WEIGHT LOSS.

SIMULATED CASE HISTORY OF PRESENT ILLNESS

• APPARENTLY HEALTHY UNTIL DELIVERY OF A BABY ABOUT 4 MONTHS AGO

• PALPITATIONS AND TREMORS THAT ARE FELT THROUGHOUT THE DAY BUT DON'T HAMPER HER DAILY ACTIVITIES.

• SIGNIFICANT WEIGHT LOSS

• INTERMITTENT DIARRHEA WITH NO NAUSEA, VOMITING OR ABDOMINAL PAIN.

• ALSO HAS A DRY COUGH FOR THE LAST MONTH BUT NO DIFFICULTY SWALLOWING OR BREATHING. 

• NO FEVERS, CHILLS, RECENT INFECTIONS, PAIN IN THE NECK AREA OR CHANGE IN APPETITE.

SIMULATED CASE PHYSICAL EXAM

• VITAL SIGNS - TEMP:  98.6 °F , HEART RATE:  125, RESP:  22, BP: 135/70

• GEN: AAO X 3, NOT IN DISTRESS.

• HEENT: PERRL, EOMI, NO PALLOR OR JAUNDICE, NORMAL HEARING, GOOD ORAL HYGIENE. EXOPHTHALMOS +, LID LAG +

• NECK: SOFT NECK SWELLING THAT MOVES WITH SWALLOWING, NO NODULARITY, 3 X 3 CM IN SIZE WITH LOWER MARGINS NOT FELT, AUDIBLE BRUIT OVER THE THRYOID MASS. NO JVD, MIDLINE TRACHEA, NO LYMPHADENOPATHY.

• CHEST: NORMAL BREATHING MOVEMENTS, NO VISIBLE SCARS.

• RESP: CLEAR BILATERAL AIR ENTRY, NO WHEEZING OR CRACKLES.

• CV:S1 S1 NORMAL, TACHYCARDIC, NO M/R/G, PULSES 2+ BILATERALLY.

• GI: SOFT, NOT DISTENDED, NO TENDERNESS,  NO ORGANOMEGALY, +BS X 4

• MSS: NO LOWER EXT. EDEMA OR SWELLING, NORMAL PASSIVE AND ACTIVE MOVEMENTS.

• NEURO: CN II-XII INTACT, NO FOCAL DEFICITS NOTICED. TREMORS +

SIMULATED LABORATORY WORK UPCBCWBC count 7 K/uLHb – 12 g/dLPlatelet count – 150 K/uL

BMPNa – 140 mmol/LK – 3.8 mmol/LCl – 106 mmol/LCo2 – 24 mmol/LBUN – 6 mg/dlCreatinine - 0.3 mg/dlCalcium - 10 mg/dlGlucose - 120 mg/dl

UA wnl

Thyroid function testsTSH – 0.02 uIU/ml (Normal range 0.34-5.60 uIU/mL)

Free T4- 6(Normal range - 0.58-1.64 ng/dL) Free T3 – 30(Normal range - 2.5-3.9 pg/mL)

TSH receptor Ab – 40( Normal range - <=1.75 IU/L)

SO YOU DIAGNOSE GRAVES DISEASE

• NOW WHAT?

HYPERTHYROIDISM

EPIDEMIOLOGY

• MORE COMMON IN WOMEN THAN MEN (5:1).

• INCREASES WITH AGE

• MORE COMMON IN SMOKERS

HYPERTHYROIDISM - NORMAL OR HIGH RADIOIODINE UPTAKE

• GRAVE’S DISEASE

• HASHITOXICOSIS

• TOXIC ADENOMA

• TOXIC MULTI-NODULAR GOITER

• IODINE INDUCED HYPERTHYROIDISM

• TSH MEDIATED (PITUITARY ADENOMA)

• HCG MEDIATED ( HYPEREMESIS GRAVIDARUM, TROPHOBLASTIC DISEASE)

HYPERTHYROIDISM -LOW OR ABSENT RADIOIODINE UPTAKE

• THYROIDITIS

1. DRUG INDUCED (AMIODARONE)

2. SUB- ACUTE GRANULOMATOUS THYROIDITIS (DE QUVERVAIN’S – PAINFUL)

3. SUB- ACUTE LYMPHOCYTIC THYROIDITIS (POST PARTUM – PAINLESS)

4. RADIATION INDUCED

5. POST SURGICAL – PALPATION THYROIDITIS

• ECTOPIC THYROID HORMONE PRODUCTION (STRUMA OVARII, FOLLICULAR THYROID CARCINOMA METS)

• EXOGENOUS THYROID HORMONE USE (EXCESSIVE LEVOTHYROXINE USE)

CLINICAL FEATURES - HISTORY• ANXIETY, INSOMNIA, TREMORS

• PALPITATIONS, NEW ONSET ATRIAL FIBRILLATION, PREMATURE ATRIAL COMPLEXES, DYSPNEA ON EXERTION

• DIAPHORESIS

• HYPERDEFECATION

• WEIGHT LOSS WITH NORMAL OR INCREASED APPETITE

• HEAT INTOLERANCE

• URINARY FREQUENCY

• AMENORRHEA OR OLIGOMENORRHOEA IN WOMEN, GYNECOMASTIA AND ERECTILE DYSFUNCTION IN MEN

• MYOPATHY, OSTEOPOROSIS

• WEAKNESS AND ASTHENIA ( APATHETIC THYROTOXICOSIS)

• WORSENING GLYCEMIC CONTROL

• CHF EXACERBATIONS

CLINICAL FEATURES – PHYSICAL EXAM• RESTLESSNESS, TREMOR, RAPID SPEECH

• TACHYCARDIA – IRREGULAR IRREGULAR, SYSTOLIC HYPERTENSION

• PROXIMAL MUSCLE WEAKNESS, HYPERREFLEXIA

• MOIST WARM SKIN

• THIN, FINE HAIR

• EXOPHTHALMOS, CONJUCTIVAL EDEMA, STARE AND LID LAG ( GRAVE’S DISEASE).

• PRETIBIAL MYXEDEMA (INFILTRATIVE DERMOPATHY)

• THYROID ENLARGEMENT (NO ENLARGEMENT IN PAINLESS THYROIDITIS VS GENERALIZED ENLARGEMENT TMN OR GRAVE’S VS. SINGLE NODULE IN ADENOMA)

LABORATORY TESTS• TSH LOW AND SERUM FREE T4 AND/ OR SERUM T3 HIGH

- SUBCLINICAL HYPERTHYROIDISM – TSH LOW, T4 AND T3 ARE NORMAL

- T3 TOXICOSIS – T3>> FT4 ( GRAVE’S DISEASE, NODULAR GOITER)

- T4 TOXICOSIS – HIGH FT4 AND NORMAL T3 DUE TO DECREASE IN THE PERIPHERAL T4 TO T3 CONVERSION (EG. AMIODARONE, CONCURRENT ILLNESS).

• TESTING FOR ETIOLOGY

- 24 HOUR RI UPTAKE SCAN

- THYROTROPIN RECEPTOR ANTIBODIES

• TSH HIGH AND FT4 AND/OR T3 HIGH

- SCREEN FOR THYROTROPIN SECRETING PITUITARY ADENOMA WITH MRI AND SERUM ALPHA SUBUNIT

- RESISTANCE TO FEEDBACK DUE TO GENETIC DEFECTS

MANAGEMENT

• BETA BLOCKERS – ATENOLOL 25-50 MG /DAY

• THIONAMIDES – FOR 3-8 WEEKS PRIOR TO ABLATION, CI IN ANC < 500 AND TRANSAMINASE ELEVATION

– METHIMAZOLE - ONCE DAILY DOSING, RAPID EFFICACY, LOWER SIDE EFFECTS, 10-30 MG DIALY

- PROPYLTHIOURACIL – PREFERRED IN THE 1ST TRIMESTER OF PREGNANCY

• IODINE OR IODINATED CONTRAST AGENTS

• RADIOIODINE ABLATION VS. SURGERY FOR PERMANENT REMISSION

• OTHER AGENTS – STEROIDS, LITHIUM, CHOLESTYRAMINE, CARNITINE, RITUXIMAB