Alexander Warren

Primary Care of Adults

09/11/2014

1. What are your initial thoughts regarding this patients diagnosis? What additional data
should you obtain from the history and physical exam?
This patient appears to be a classic case of hyperthyroidism upon initial exam and questioning. The
patients weight loss, increased heart rate, sweats, irritability/anxiety, thinning hair, reduced libido, and
bruit over the thyroid are all signs of hyperthyroidism. The patient also states that her constipation is
gone. Diarrhea is a symptom of hyperthyroidism, so a relief of constipation also alerts you to this
problem. In regards to additional information, we should know if the patient has a family history of
hyperthyroidism. We know she has a bruit over the thyroid but is the thyroid enlarged? Does the
patient have exophthalmos, pretibial myxedema, and a goiter which would reveal Graves disease?
Graves disease being the most common cause of hyperthyroidism. How long has the patient had these
symptoms, what are her drug allergies, and we need to update her medical history. What are the
patients current medications? Is the patient taking any thyroid preparations to help with weight loss?
Is she a smoker or has she had any trauma/surgery to the thyroid gland? Has she had an increase in her
iodine intake (diet or medications like amiodarone or lithium)? Does she have to use HAART as this can
affect the thyroid? Does she have type 1 diabetes or pernicious anemia as hyperthyroidism can be
associated with those conditions.
2. What laboratory tests and other diagnostic procedures may you need to consider to make
an accurate diagnosis?
The initial testing for hyperthyroidism begins with a TSH and a Free T4 (FT4). The results of the TSH and
the Free T4 determine what your next step should be. As with all tests, the goal is to find the cause of
the problem. Many things could be causing the thyroid level to be high. The patient could have Graves
disease, a goiter, an adenoma, thyroiditis, tumors, or many other things. If the FT4 is normal, you
should perform a T3 due to some hyperthyroidism patients having a normal FT4 but their T3 levels are
elevated. If TSH levels are low and the T4 is normal the patient could have thyrotoxicosis. Scintigraphy
is also used but some studies have shown thyroid scintigraphy and uptake studies did not influence
diagnosis or treatment outcomes in most cases of hyperthyroidism. (Okosieme, 2010) A radioadsorbed
iodine uptake (RAIU) test is more useful and can differentiate between several types of conditions that
cause hyperthyroidism such as nodular goiters, Graves disease, and thyroiditis. Depending on how
much radioactive tracer is absorbed and where you can differentiate between certain diagnoses.
Graves disease and nodular goiters absorb a lot of tracer where thyroiditis, toxic adenoma and
multinodular goiters absorb little. Patients diagnosed with thyrotoxicosis should have a thyroid scan to

monitor for malignancy. If masses are palpated a fine-needle biopsy should be obtained to rule out
tumors and ultrasounds will differentiate between a cyst and a nodule.
3. How would you explain the laboratory results to this patient in a language that she could
understand?
Hyperthyroidism is one of the more difficult conditions to explain in laymens terms. The thyroid
controls how sensitive you are to hormones and it produces hormones. By doing so, it controls how fast
your body burns energy. How much or how little hormones your thyroid makes is changed by how
much TSH is in your blood. It goes both ways too; the amount of T3 and T4 in your blood sends signals
to your thyroid to make more or less TSH. This is why we check the TSH. It can give us answers to
several questions. When performing the RAIU the patient will swallow a very small amount of
radioactive iodine. The thyroid will absorb this iodine and we look at the thyroid in about 5 hours and
again after 24 hours. The thyroid will normally absorb between 15% - 25% of the iodine. If the thyroid
absorbs less or more then it will give us an idea of what is causing the hyperthyroidism. The thyroid
scan is similar to the RAIU in that the patient swallows a radioactive agent but the scan uses imaging to
diagnose the disease. It is used to show the size and shape of the thyroid and it shows what areas are
overactive or underactive. A fine-needle biopsy is where the physician uses a very small needle to take a
piece of the patients thyroid so they can look at it under a microscope and determine if there are any
cancerous cells. An ultrasound for the thyroid is not unlike an ultrasound that a pregnant woman has. It
uses sound waves to draw a picture of what the thyroid looks like and can give the physician a better
picture of the thyroid.
4. How would you treat this patient? Provide rationales from the current literature for your
management plan. What health promotion strategies are especially important for this
patient at this point in time and why?
I do not know how I would treat the patient before the tests are performed. There are many things that
could be causing the patients symptoms and it is unwise to treat a patient until a diagnosis has been
made. For the sake of this exercise I will assume the patient has Graves disease which is the most likely
cause of these symptoms. Current AACE guidelines for the treatment of Graves disease include one of
three different types of treatment. Radioactive iodine, antithyroid drugs, or surgery are used in the
treatment and it was found that the quality of life following treatment for Graves disease was the same
in patients who were randomly given one of the three options for treatment. (AACE, 2013) Since
current guidelines reveal that all options seem to have similar outcomes I would elect to go with a
nonsurgical option but I would take the patients preference as a consideration. We would need to
perform a pregnancy test prior to beginning iodine therapy if we chose that option. The patient needs to
eat a higher number of calories per day due to her weight loss. She is burning more calories so she
needs to replace them. Also hyperthyroidism can contribute to thinning bones so an increase in calcium
is important.

5. What would you build into her plan of care other than pharmacological management?
The patient needs teaching on diet as stated above; increase in calories and calcium. Also with Graves
disease you will probably experience eye problems. Apply cool compresses to provide extra moisture.
Use lubricating eye drops and wear sunglasses. The patient may have swollen/irritated skin on her shins
and feet so OTC medications like hydrocortisone could help. Increase weight bearing exercise to help
with bone density and learn techniques to help you relax because she will have a continued increase in
anxiety.
6. What follow-up does this patient require? What patient education?
The patient will need frequent follow ups for blood work to monitor the effectiveness of the
medications. Initial lab work to be done after one month and again in 3 months. Thyroid function
should be done twice a year once levels have stabled, more if patient is symptomatic. The patient may
need a referral to endocrinology. The patient will defiantly need a referral to an ophthalmologist for an
evaluation. Watch for side effects of thyroid medications such as fever, sore throat, and throat ulcers.
Do not take OTC medications that contain pseudoephedrine, ephedrine, and alpha-adrenergic agonists.
Monitor weight daily. Use your pulse as a guide when exercising. Avoid severe fatigue and stop
immediately if palpitations occur.
7. Are any Healthy People 2020 objectives relevant to this case?
In regards to Health People 2020 there are several objectives that relate to people suffering from
Graves disease. Vision problems are a huge problem and the V-4 objective is to increase the proportion
of adults who have comprehensive eye examinations. (Health People 2020) Eye exams with an
ophthalmologist are essential for patient with Graves disease. Patients who have hyperthyroidism
excrete calcium at a higher rate than people who do not suffer from the disease. NWS-20 attempts to
increase the consumption of calcium in the population aged 2 years and older. (Healthy People 2020)
With increased anxiety and irritability sleeping becomes an issue with most patients who suffer from
hyperthyroidism. SH-4 creates an objective to increase the proportion of adults who get sufficient sleep.
(Healthy People 2020) The decrease in calcium leads to a high number of people who develop
osteoporosis due to Graves disease. AOCBC-10 has the goal to reduce the proportion of adults with
osteoporosis.
8. What are standard screening recommendations for thyroid function?
Screening for thyroid function is not recommended for patients without symptoms. Patients who
complain of 1-2 symptoms may be no more likely to have abnormal thyroid function than those who
have no symptoms. Usually providers check a TSH if the patient presents with 3 or more symptoms of
hyperthyroidism.
Bahn, R. S., Burch, H. B., Cooper, D. S., Garber, J. R., Greenlee, M. C., Klein, I., ... Stan, M. N. (2013).
Hyperthyroidism and other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid

Association and American Association of Clinical Endocrinoloigists. Endocrine Practice, 17(3), 456-520.
doi: 10.4158/EP.17.3.456
Okosieme, O. E., Chan, D., Price, S. A., Lazarus, J. H., & Premawardhana, L. D. (2010). The utility of
radioiodine uptake and thyroid scintigraphy in the diagnosis and management of
hyperthyroidism. Clinical Endocrinology, 72(1), 122-127. doi: 10.1111/j.1365-2265.2009.03623.x