1. Medical Grand Rounds Clinical Vignette December 3, 2008 Steven Giovannone, MD

2. Chief Complaint A 42 year old female presents to the emergency room with palpitations for 1 week.

3. History of Present Illness The patient was in her usual state of good health until two months prior to admissions. During that time, the patient noticed a weight loss of 10 pounds despite normal appetite and food intake. She also noted loose stools and insomnia. One week prior to admissions, the patient noted increased irritability and has been experiencing palpitations both at rest and with exertion.

4. Additional history Past Medical History: Hyptertension Past Surgical History: none Family History: Hypertension in both parents and a brother Social History: Born in the US, denies any toxic habits Medications: HCTZ 25 No known allergies

5. Physical Exam General: Anxious appearing African American female in no acute distress Vital Signs: T 98.2 P 104 BP 185/95 O2 sat 100% RA HEENT: + lid lag, + proptosis Neck: Palpable, diffusely enlarged, non-tender thyroid with audible bruit Neuro: Hyperreflexive patellar reflexes, mild resting tremor Skin: warm, smooth The remainder of the physical exam was unremarkable

6. Laboratory Data Basic metabolic panel, hepatic function panel, complete blood count within normal limits Troponin negative TSH < 0.004 (0.35-4.8) Free T4 3.5 (0.9-1.9) Free T3 5.4 (2.3-4.2) EKG showed sinus tachycardia without ischemic changes or LVH Chest XRay was normal in appearance without cardiomegaly

7. Working Diagnosis Graves’ Disease

8. Initial management Patient was started on propranolol TID to target resting HR of 60, and methimazole 5 mg TID Symptoms improved and hypertension resolved with treatment Radioiodide uptake scan showed high uptake in a diffuse pattern Thyroid-stimulating antibodies and thyrotropin receptor antibodies were sent and were pending at time of discharge Patient was discharged with follow-up in endocrinology clinic for possible radioiodine ablation in the future

9. Final Diagnosis Graves’ Disease