Abdallah Al Marzouki, M.D.

A 37 year old previously healthy woman presents to your clinic for unintentional weight loss. Over the past 3 months, she has lost approximately 15 lb without changing her diet or activity level. Otherwise, she feels great. She has an excellent appetite, no gastrointestinal complaints except for occasional loose stools, a good energy level and no complaints of fatigue. She denies heat or cold intolerance.

On examination, her heart rate is 108 bpm, blood pressure142/82 mmHg, and she is a febrile. When she looks at you, she seems to stare, and her eyes are somewhat protuberant. You note a large, smooth, nontender thyroid gland, a 2/6 systolic ejection murmur on cardiac examination, and her skin is warm and dry. There is a fine resting tremor.

Perform T. F. T. ⇩ TSH⇧⇧ T4 TSI – Thyroid Stimulating Immunoglobulin TRAB – Thyroid Receptor Antibodies

 Antithyroid drugs  Radioactive Iodine ablation  Surgical

1. Understand the clinical presentation of thyrotoxicosis. 2. Be able to discuss the causes of hyperthyrodism, including Grave disease and toxic nodule. 3. Learn the complications of thyroxicosis, including thyroid storm. 4. Understand the evaluation of a patient with a thyroid nodule. 5. Know the available treatment options for Grave disease and outcomes of treatment.

 The most common cause of thyrotoxicosis is Grave disease. No other diagnosis is likely if the patients has bilateral proptosis and a goiter.  In patient s with Grave disease, thyrotoxic symptoms may be treated with antithyroid medication or by thyroid gland ablation by radioactive iodine or surgery, but the ophthalmopathy may not improve.

 Graves disease may remit and relapse; in patients treated medically, one third to half will become asymptomatic within 1 to 2 years.  After radio ablation, most patients with Grave disease become hypothyroid and will require thyroid hormone supplementation.

 Hyperfunctioning thyroid nodules - (excessive thyroid hormone production, suppressed thyroid-stimulating hormone, ‘hot’ on radionuclide scan) almost never are malignant.  Most ‘cold’ thyroid nodules are not malignant, but fine-needle aspiration should be used to evaluate the need for surgical excision.

Thyroid Disorders Functional - Thyroid overactivity - Thyroid underactivity Structural - Simple Goiter - Nodular Goiter - Multinodular Goiter - Cancer

 A 31-year-old lady presents to the medical outpatients department with a history of hoarseness of voice for the last 6 months. She also complaints of lethargy, constipation and weight gain of about 5 kg during the same period. She has been aware of a swelling in the front of her neck for the last 3 months.

 Her menstrual cycles are regular, but she complains of very heavy menstrual bleeding. She is not on an oral contraceptive pill. Her past history has been uneventful without any operative procedure or major illness. She has no history of head and neck irradiation; neither is there any specific drug history. Her two sons, aged 4 years and 2 years, are healthy.

 Physical examination reveals a puffy face with oedematous eyelids, mild pallor and non- pitting oedema (myxoedema). The patients body weight is 65 kg and he body mass index is 28. her blood pressure is 150/95 mmHg. There is a diffuse goiter which is firm and non-tender, without any associated bruit. The ankle jerks are delayed bilaterally. There is no other specific finding on physical examination.

 PRL ⇧  Cholesterol ⇧  Pregnancy (TBG ⇧ - FT4 / FT3)  Medication (drugs)  Infertility ( pregnancy desire)