16-year-old with ADHD presents with chest pain and exophthalmos (watch video)
Patient will present as → a 34-year-old female complaining of irritability and nervousness, heat intolerance with increased sweating, and weight loss despite an increase in appetite. On physical exam, you note exophthalmos and pretibial myxedema. She has a pulse of 110, a fine tremor and 4+ deep tendon reflexes. Her hair is fine in texture and you note a palpably enlarged thyroid gland.
Patients will present with weight loss, anxiety, tachycardia, and EKG changes such as PVCs.
- Physical exam findings will include fine, thin, moist skin, prominent eyes with lid retraction (proptosis, or exophthalmos) and a startled expression.
- The patient will complain of heat intolerance, palpitations, weight loss, tachycardia, and anxiety
- Physical exam will demonstrate hyperreflexia, and goiter (enlarged thyroid gland)
- Labs will show low TSH and high free T4
- Most commonly caused by Graves disease (autoimmune against TSH receptor)
- Treatment is methimazole or PTU
- Comments: Propylthiouracil (PTU) P for pregnant
Thyroid storm is an acute form of hyperthyroidism that results from untreated or inadequately treated severe hyperthyroidism. It is rare, occurring in patients with Graves disease or toxic multinodular goiter (a solitary toxic nodule is a less common cause and generally causes less severe manifestations). It may be precipitated by infection, trauma, surgery, embolism, diabetic ketoacidosis, or preeclampsia. Thyroid storm causes abrupt florid symptoms of hyperthyroidism with one or more of the following: fever, marked weakness and muscle wasting, extreme restlessness with wide emotional swings, confusion, psychosis, coma, nausea, vomiting, diarrhea, and hepatomegaly with mild jaundice. The patient may present with cardiovascular collapse and shock. Thyroid storm is a life-threatening emergency requiring prompt treatment.
Diagnosis: Low TSH, with high T3 and T4 confirms hyperthyroidism, but with Graves’ disease usually, only the T3 is elevated
- ↓ TSH
- ↑ Free T4, plus either free T3 or total T3
- Sometimes radioactive iodine uptake
- Graves: Anti-thyrotropin antibodies
The cardiac symptoms of Graves’ disease can be treated with β-Blockers
- Most often atenolol 25-50 mg PO QD is the starting dose, and it can be increased up to 200 mg PO QD if the blood pressure tolerates.
To treat Graves disease antithyroid drugs (methimazole or PTU), radioactive iodine and surgery (thyroidectomy) are all used depending on the patient.
- Methimazole may be given; starting dose for mild hyperthyroidism is 10 mg PO QD.
- Propylthiouracil (PTU) P for pregnant
Complications: dysrhythmias, osteoporosis, thyroid storm, CHF, pregnancy issues including miscarriage
toxic multinodular goiter
radioactive iodine uptake test
thyroid ultrasound study
free serum thyroxine (T4)
serum thyroid-stimulating hormone (TSH)
radioactive iodine uptake
fine-needle aspiration (FNA) of thyroid
TSH receptor antibodies