Hyperthyroidism

Casebank History
1

Where you are:
You are working as a Foundation Year 2 doctor in General Practise.
Your next patient is a 24-year-old lady, Emma White, who has presented with some concerns.

Other information you have about the patient:
None

What you must do:
Please assess the patient and discuss initial management plan with the patient.

Where you are:
You are FY2 in general practice

Who the patient is:
Patricia Moore 27-year old lady who had presented to your GP practice with sweating and shaking in her hands

Other information you have about your patient
On her last visit one week ago the blood tests were done which are as follows:

Thyroid Function Tests
TSH 0.6 (0.5-4.5 ug/dl)
T4 22 (4.6-12 ug/dl)
T3 235 (80-180 ng/dl)
Pulse 90/min, BP 130/80

What you must do
Please a focused history and discuss initial management with the patient.

Where you are:
You are working as a Foundation Year 2 doctor in General Practise.

Who your patient is:
Helen Morrison a 33 year old lady who has made an appointment to see you.

Other information you have about the patient:
None

What you must do:
Please assess the patient and discuss management.

Patient Information

Scenario A

  • You are Emma White, a 24 year old lady. Your boyfriend brought you to see the doctor.
  • You should tell/ask the doctor:
  • You have lost 3 stones weight in the last 3 months
  • Your boyfriend noticed the weight loss, but you also know you have lost weight
  • You have had loose stools for the past 2 months
  • You feel hot and sweaty when others are comfortable
  • Your periods are light and irregular for 3 months
  • Your sister and mum were diagnosed as having hyperthyroidism
  • Your mother is on medication
  • You have some palpitations.
  • You are worried that weight loss is due to cancer.
  • Your boyfriend has asked you to see the Gp because he noticed the weight loss.

Scenario B

  • Opening sentence: “I have got thumping in the chest”
  • You have had thumping in the chest and weight loss for the past 3 weeks
  • You have also noticed that your stools are a bit loose
  • You also prefer cold weather because you cannot handle heat
  • You feel that your clothes are loose on you
  • Your friends have also commented that you have lost weight

Questions:

  • What do you think is wrong doctor
  • Will you give me any medications
  • Does this medication have any side effects

Examiners Prompt: If the candidate says he would like to perform thyroid function tests, give him the results of the thyroid function test

Emotions And Attitude:

  • Right hand is shaking.
  • You are holding hands together.
  • LMP 6 weeks ago.
  • You have had weight loss.
  • Your clothes are loose on you.

Questions:
Could it be menopause?
What is wrong with me?

Examiner’s Prompt:

  • The candidate should ask to perform examination after which the examiner should say assume it has been performed and is normal.
  • Pulse 90/min, BP 130/80

Investigations:

  • Show only if the candidate mentioned that he needs to perform
  • TFT show normal T3 and T4 but TSH in the lower range

Treatment: Further blood tests, surgery, Carbimazole, Radioiodine therapy

Blood Test: Check for hormones in your blood, which are produced by the thyroid gland and those that control the thyroid gland.

Questions:

  • What is wrong with me?
  • How will you manage me?
  • What medications will you give me?
  • What is radio-iodine doctor?

Approach:

  • GRIPS
  • How can I help you? (do you feel that you have lost weight)
  • History of weight loss (any swelling of the neck, ODPARA, D/Ds, P3MAFTOSA) (symptoms: weight loss, tremor, irregular periods, palpitations, diarrhoea, feels hot when others are comfortable)
  • Anyone in the family with thyroid problems?

Explain most likely diagnosis :

  • So you have told me that you have tremors and sweating of your hands for the past 2 months and you have lost 3 kgs in weight,your periods have become irregular and that your mother has got thyroid problems, is there anything else that I have missed?
  • From what you have told me I feel that you have a condition called hyperthyroidism This is the same as an over active thyroid.
  • To confirm the diagnosis I will need to perform some examinations + investigations.

Examination:

  • Thyroid gland in your neck,
  • Check (pulse, RR, BP,) check for any tremors,
  • CVS-listen to heart,
  • Check for reflexes.
  • Blood test to check how your thyroid is functioning. (fbc, u&e, lft, glucose)
  • Now I understand that you had some blood tests done a week ago.
  • Okay, let me have a look at your blood tests again.
  • Now these blood tests also confirm that you have got this hyperactive thyroid.
  • This condition is not a genetic disease but it can run in your family sometimes.

ICE:

  • Ideas - Patient worried that the weight loss is due to cancer.
  • Concerns - Reassure that the weight loss is due to overactive thyroid.
  • Expectation - If at all it’s cancer of the thyroid it can be treated but it’s highly unlikely
  • Social issues: your living, effect on daily activities.

P: So what are you going to do for me now?

Management:

  • Refer to Endocrinologist,
  • Treatment options
    • Medication to suppress overactivity (Carbimazole), B-blockers, Radio-iodine,
    • Operation (complete removal of the thyroid and put you on replacement medication)
    • Specialist may also perform blood (Auto-antibodies) and USS.
  • Leaflets
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