- An otherwise healthy 36-year-old woman presents with 8 months of feeling anxious and tremulous. On examination her pulse is 115 per minute, BP 155/90 and there is a moderately enlarged, non-tender, non-nodular thyroid and hyperreflexia.
(a) What is your clinical diagnosis?
(b) What tests would you order? What would you expect the results to be?
© What are the main treatment options for this patient?
b) Heck, I don’t know…I’m still months away from medschool, but an obvious blood draw should be drawn to look for abnormal hormone levels.
c) Uhhhhhh…check please???
I’d say hyperthyroidism
Tests; TSH, antibody thyroid test for Graves disease and to rule out autoimmune thyroiditis, also radioactive thyroid scan and iodine uptake tests to find out why thyroid is overactive
Treatment options : for those under 50 years of age, pregnant, nursing or mild cases, an anti-thyroid medication
for those over 50 and not in one of those special populations: irradiation of the thyroid and thyroid replacement hormone
Hope this helped!
Okay, Joe. From a PBL point of view.
First, I want more of the physical exam. HEENT, abdominal, musculoskeletal, neurological, cardiovascular, etc. Also, history. . . any weakness, fatigue, sweating, dyspnea, weight loss, tremors, etc? What about family history? Diabetes, heart disease, malignancies? How long has she had the symptoms? What precipitated them? Does anything help? Is she taking any medications?
After that, I MIGHT make a differential diagnosis of: hyperthyroidism, anxiety, malignancy, diabetes, Graves, pregnancy or menopause.
Tests: Thyroid panel (T3, T4), Thyroxin and thyroxin index, and a TSH. If necessary follow with an RIU (radioiodine uptake). Would also get a CBC, UA, and a chem panel to include glucose.
When I get the history, physical, and lab reports, THEN I’ll make my diagnosis.
Just $0.02 from a PBL point of view. . .
(a) Hyperthyroidism which, clinically and epidemiologically, is likely to be Graves’ disease.
(b) Serum TSH will be low, often undetectable. Serum T4 and T3 will be high. Serum microsomal and thyroglobulin antibodies will be present in the serum in most cases of Graves’ disease.
© Antithyroid drugs given for ~2 years in the hope that the disease remits on its own. These include:
" Carbimazole, most often used in the UK
" Methimazole, the active metabolite of carbimazole, used in the USA
" Propylthiouracil, occasionally used.
Beta-blockers for symptomatic relief, but they do not alter the course of the disease.
Radioiodine is more commonly preferred for definitive treatment of Graves’ disease, surgery is particularly suited to patients with large goitres which are unlikely to remit after medical treatment.
Both were right, however, on the USMLE, you don’t get the chance to examine the patient so thoroughly. You have to go with what you know to be correct as far as you can tell. You are thorough tho Linda, I will give you that. Very much so.
BTW, in the case, it was said she had the symptoms for 8 months.
Good job guys!!!
and two of us aren’t even IN medical school YET!