CASE

A 26-year-old-receptionist presents with palpitations and weight loss. Although pleased about
the weight loss, the patient is concerned that her menstrual periods have stopped and it is the
anxiety related to this, she believes, that is responsible for disturbing her sleep. Her partner has
insisted that she seek a medical opinion.

For the case scenario given, consider the following:

Q1: What do you think the likely diagnosis is?

Hyperthyroidism is the abnormal function of your thyroid gland, an organ located in the front of
your neck that releases hormones to regulate your body’s use of energy. In other words, if your
thyroid gland is overactive and makes more thyroid hormones than your body needs, it causes
hyperthyroidism.

The hormones produced by your thyroid gland are thyroxine (T4) and triiodothyronine (T3), and
they play an important role in the way your entire body functions. For this reason, when there is
an imbalance, it can have far-reaching effects on almost every aspect of your health.

Q2: What tests could you do to confirm this?

To confirm the disease the disease present to the patient , the test needed are the Thyroid function tests
and free thyroxine. Thyroid Function test is to measure the TSH(Thyroid Stimulating Hormone)level in a
blood sample. TFTs may be requested if a patient is thought to suffer from hyperthyroidism or
hypothyroidism, or to monitor the effectiveness of either thyroid-suppression. And for Free thyroxine(free
T4) tests are used to evaluate thyroid function and diagnose thyroid diseases, including hyperthyroidism
and hypothyroidism, usually after discovering that the thyroid stimulating hormone(TSH) level is
abnormal. These 2 laboratory test is recommended to determine whether the patient had a
hyperthyroidism or hypothyroidism which indicate what type of disease present to the patient.

Q3: What tests would help establish the cause?

Clinically the presence of graves eye disease establishes the diagnosis in a patient presenting with
thyrotoxicosis, and no further investigations need to be done. Similarly,if a thyroid bruit is present, this
too is unequivocal evidence of primary hyperthyroidism and exclude thyroiditis and the effects of
exogenous thyroid hormones. Thyroid Autoantibodies are usually present,but this test is not often
particularly helpful.
Imaging the thyroid either using ultrasonography or isotope scan is not often required in patients
presenting with hyperthyroidism. Confirming the presence of a solitary ‘hot nodule’ ; however can be
useful because radioiodine is a more appropriate treatment than antithyroid medication, which although
effective, would have to be continued in the long term maintain euthyroidism

Q4: What is the initial management?

Hyperthyroidism caused by overproduction of thyroid hormones can be treated with antithyroid

medications (methimazole and propylthiouracil), radioactive iodine ablation of the thyroid gland, or
surgical thyroidectomy.

The initial management is to provide with carbimazole at 40 mg daily, followed by

thyroxine after a few weeks, is probably the safest way to restore euthyroidism quickly.

The patient should be warned that carbimazole can cause dangerous neutropenia on a
case-by-case basis, with a sore throat being the first sign. If these symptoms occur, the
patient should be advised to discontinue the drug immediately and seek medical attention.

An alternative to the block and replace regimen described above is to treat with
carbimazole alone and repeat thyroid function tests every 3-4 weeks, gradually reducing
the carbimazole dose as the condition improves, aiming for a dose of 5-10 mg daily after
2-3 months.

Q5: What are the long-term complications/sequelae?