PBL: Graves’ Disease

Keywords:

• 35 y.o female secretary (brought in crying after a fight with her boyfriend, accuse him of hitting her)
• Fast & loud heartbeat
• Often anxious, nervous and unable to concentrate on her work (symptoms worsening)
• Could not tolerate hot temperature
• BP: 150/80 mmHg
• Pulse regular, pulse rate: 100 per minute
• Skin is warm & moist, sweaty palms & fine tremors
• Large starring eyes
• full bood count: no anaemia
• Normal liver function tests
• TSH level decreased, free T4 is increased
• Thyroid antibody test positive, TSI/LATS (autoimmune)
• Thyroid scan: diffusely enlarged gland with increased uptake of radioactivity

Hypothesis

Graves’ Disease

Learning issues:

Why do we perform a liver function test?

To monitor liver toxicity caused by thioamides (an antithyroid medication)

What is the expected blood picture for a patient with hyperthyroidism?

• normocytic anemia (maybe)
• decreased white blood cell
• decreased platelet

What other investigations we can do?

• Gynecomastia
• increased sex hormone-binding globulin levels, decreased free testosterone level
• Diabetes (haemoglobin A1C)
• Fasting lipid profile (decreased total cholesterol level)
• High titre serum antibodies to collagen X11 (associated with active Graves’ ophthalmology)

What is the implication if a pregnant patient is suffering from maternal Graves’ disease?

Neonatal toxicosis of the infant