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Hyperthyroidism

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor in family medicine. Your next patient is Charlotte Watson, a 48-year-old receptionist who presented with weight loss over the last month. Please take a history and perform a relevant examination.



 

Patient History:


You have noticed you lost some weight 2 months ago as your trousers seem not to fit anymore. They are now too big for you – you have found it inconvenient to buy new pants that fit! You haven't changed anything about your diet or exercise regime and don't know why you have lost weight. You however do feel hungry all the time, usually wanting to eat more after a meal as nothing seems to be filling you up! You also noticed that you become flushed easily, especially when the room is warm, and you need to get outside to cool yourself down, but you think because of your age, it is down to reaching menopause as your periods also become more irregular and lighter than usual. This, however, hasn't caused you any trouble.


You noticed that sometimes your heart beats very fast as if you have just been doing cardio at the gym! When this happens, you have to relax and rest for a while to recover from these episodes. You haven't slept well and seemingly can't switch off at night. You think possibly this is down to stress from work. You haven't experienced any changes in your mood – you are still happy about your life and look forward to going out with friends on weekends.


You have noticed diarrhoea recently; there's no blood/mucus in it. You haven't eaten anything abnormal recently. No fever. No recent infections. You also have found your eyes feeling quite uncomfortable. They are always dry and gritty. You've not noticed any changes in vision, and you don't think your eyes look any different than usual. You haven't noticed any lumps in your neck.


Mention only if asked: you have realised that your hair has also become quite thin and untidy. You are really surprised that the hair falls out more easily than usual. You tried to use some thickening products to help thicken the hair, but it is not very useful.


Ideas, Concerns, Expectations:

  • You think you are experiencing these symptoms due to reaching menopause. You are worried that because many of your family members suffered from bowel cancer and lost weight, you might have it too. However, you do feel well, so you don't think this is the reason causing the symptoms. Therefore, you want to discover what is happening – as the symptoms don't seem to disappear!


Past Medical History:

  • None


Drug History:

  • None, allergic to penicillin > rash


Family History:

  • Dad and brother have bowel cancer. Mum has coeliac disease.


Social History:

  • You live alone with your husband, who looks after you.

  • You have two children who are still at school and are in good health.

  • You work full-time as a receptionist in a busy surgery clinic.

  • You smoke 20 cigarettes a day for 20 years except when pregnant.

  • You drink alcohol e.g. a glass of wine every week with food.

 

Examination Findings:


Possible examination findings include:

  • Diffuse Goitre (without nodules)

  • Bilateral Exophthalmos

  • Pretibial Myxoedema

  • Irritability

  • Cardiac flow murmur

  • Moist velvety skin

  • Scalp hair loss

  • Muscle weakness

  • Thyroid bruit

  • Onycholysis

  • Vitiligo

  • Acropachy


 

Differentials:

  1. Graves’ Disease (thyroid eye symptoms, examination findings, family history of autoimmune disease)

  2. Peri-menopause (due to flushes, irregular periods and age)

  3. Colon Cancer (weight loss + FH)

  4. IBD / IBS


 

Investigations:

  • TSH (primary vs secondary)

  • T3/T4 (elevated, except in subclinical disease)

  • Radioactive iodine/ technetium 99 uptake (elevated)

  • Thyroid isotope scan (diffuse uptake in Graves' disease)

  • TSH receptor antibodies (TRAb) – positive in Graves' disease

  • Thyroid ultrasound +/- fine needle aspiration biopsy

  • CT /MRI scan of orbit


Other investigations to consider if indicated based on this case:

  • Colonoscopy +/- biopsy / CT/ CEA/ FIT (colon cancer)

  • Faecal calprotectin / colonoscopy + biopsy (IBD)

  • Oestrogen/ Progesterone (low in menopause)

  • FSH/ LH (high in menopause)


 

Management (Grave's Disease):

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