Transcript Medical Grand Rounds December 3, 2008 Clinical Vignette

Medical Grand Rounds
Clinical Vignette
December 3, 2008
Steven Giovannone, MD
Chief Complaint
A 42 year old female presents to the
emergency room with palpitations for 1
week.
History of Present Illness
The patient was in her usual state of good
health until two months prior to
admissions.
During that time, the patient noticed a
weight loss of 10 pounds despite normal
appetite and food intake. She also noted
loose stools and insomnia.
One week prior to admissions, the patient
noted increased irritability and has been
experiencing palpitations both at rest and
with exertion.
Additional history
Past Medical History: Hyptertension
Past Surgical History: none
Family History: Hypertension in both
parents and a brother
Social History: Born in the US, denies any
toxic habits
Medications: HCTZ 25
No known allergies
Physical Exam
General: Anxious appearing African American female in
no acute distress
Vital Signs: T 98.2 P 104 BP 185/95 O2 sat 100% RA
HEENT: + lid lag, + proptosis
Neck: Palpable, diffusely enlarged, non-tender thyroid
with audible bruit
Neuro: Hyperreflexive patellar reflexes, mild resting
tremor
Skin: warm, smooth
The remainder of the physical exam was
unremarkable
Laboratory Data
Basic metabolic panel, hepatic function panel,
complete blood count within normal limits
Troponin negative
TSH < 0.004 (0.35-4.8)
Free T4 3.5 (0.9-1.9)
Free T3 5.4 (2.3-4.2)
EKG showed sinus tachycardia without ischemic
changes or LVH
Chest XRay was normal in appearance without
cardiomegaly
Working Diagnosis
Graves’ Disease
Initial management
Patient was started on propranolol TID to target resting
HR of 60, and methimazole 5 mg TID
Symptoms improved and hypertension resolved with
treatment
Radioiodide uptake scan showed high uptake in a diffuse
pattern
Thyroid-stimulating antibodies and thyrotropin receptor
antibodies were sent and were pending at time of
discharge
Patient was discharged with follow-up in endocrinology
clinic for possible radioiodine ablation in the future
Final Diagnosis
Graves’ Disease