Case 5 - 30 yo female with palpitation

Question 1

Symptoms of hyperthyroidism

Answer 1

weight loss, heat intolerance, tremor, increased sweating, hyperreflexia, diarrhea, light periods, A fib

Question 2

Etiologies of hyperthyroidism

Answer 2

1. Toxic diffuse goiter (Grave’s disease) - causes majority of hyperthyroidism, autoimmune disease caused by antibody that acts at TSH receptor, assoc with autoimmune disorders, can see pretibial myxedema, exophtalmus or proptosis, triggers include stress, high iodine intake, pregnancy
2. Toxic nodular goiter - thyroid nodules are common but most are not functional
3. Thyroiditis - inflamed thyroid
4. Excessive iodine

Question 3

Causes of goiter

Answer 3

lack of iodine, hashimoto’s disease, grave’s disease ,nodules, thyroid cancer, pregnancy, thyroiditis

Question 4

Hypothyroidism symptoms

Answer 4

weight gain, cold intolerance, pedal edema, heavy periods, fatigue

Question 5

Hyperthyroidism physical exam

Answer 5

• thyroid exam
• deep tendon reflexes (hyperactive in hyperthyroidism)
• can find ankle clonus or tremor, lid lag

Question 6

Differential diagnosis of palpitations

Answer 6

1. Cardiac arrhythmias - often cause palpitations, lightheadedness, chest pain, shortness of breath
2. Anxiety and panic disorder - commonly cause palpitations and SOB
3. Anemia - tachycardia due to hypovolemia
4. Hyperthyroidism
5. Drug/caffeine abuse - caffeine, cocaine, alcohol
   Less likely: dehydration, aortic stenosis

Question 7

Studies for palpitations

Answer 7

• TSH and free T4
• CBC
• EKG

Question 8

Work up for hyperthyroidism

Answer 8

• RAIU- radioactive iodine uptake - graves disease would have high RAIU and diffuse, thyroiditis would show low RAIU
• thyroid ultrasound - evals for nodules and enlargement
• thyroid antibodies

Question 9

management of hyperthyroidism

Answer 9

• propanolol for sx
• methimazole or PTU to block thyroid gland from making more thyroid hormone
• oral radioactive iodine - transient soreness, can’t do if pregnant, eventually patients often get hypothyroid and need replacement, check tsh every 2-3 months
• surgery - not recommended as first line therapy

Question 10

Management of hypothyroidism

Answer 10

• manage with levothyroxine
• increase dose slowly, esp in elderly patients
• check TSh one month after starting, continue to check until stabilized