Too Much of Anything is
Good for Nothing
A Case of Hyperthyroidism
A Case Management Presentation
Presented by:
Dr. Jason M. Mirasol
First Year IM Resident
Moderator:
Dr. Jerry Castro
Internal Medicine
Resource Speakers:
Dr. Abigail Canto
Endocrinology
Dr. Michael Reyes
Cardiology
House Rules
1. Please mute your microphones at all times while the presenter is
speaking.
2. At certain points during the presentation, the moderator will open the
forum for questions.
a. Even while the case is being presented, you may type the questions
in the chat area.
b. Once the moderator allows questions, you may also raise your hand,
request permission to speak & unmute yourself.
c. Please do not forget to mute your microphone again after speaking.
Objectives
• To apply the guidelines of the American
Thyroid Association Guidelines in the
diagnosis of hyperthyroidism
• To correlate patient’s management to current
guidelines of the American Thyroid Association
• To identify the prevalence of hyperthyroidism
in the Philippines according to the Philippine
Thyroid Association
DIFFERENTIALS
Palpitations
DIAGNOSTICS
•Drug-induced
•Cardiac dysrhythmia
ECG: sinus
•Anxiety disorder
tachycardia
Burch and
TSH LOW Wartofsky Score
PROFILE FT3 FT4 HIGH (+) fever 40
Palpitations
33/F (+) tremors
(+) heat Impending thyroid
(+) tremors HYPERTHYROIDISM intolerance storm
(+) heat (+) tachycardic
intolerance
(+) tachycardic Anti-thyroid drug
Beta blocker
TREATMENT Hydrocortisone 100mg IV
now then 50mg IV every 6
hours
Patient Profile
AGE: 33
GENDER: FEMALE
NATIONALITY: FILIPINO PALPITATIONS
CO-MORBIDS: NONE
History of Present Illness
palpitations palpitations palpitations
2 weeks PTA 2 weeks PTA Few hrs PTA
•No recent intake •consult at AHMC- •No nausea/
of caffeine ER vomiting
•No nausea/ • ECG: sinus •No bloatedness
vomiting tachycardia •No fever
•No bloatedness • Metoprolol •No cough
•No fever 100mg tablet •No dysuria
•No cough • Veramapil 5mg
•No dysuria tablet x 2 doses
•Advised
admission but
patient refused and
opted to DAMA.
Past Medical History
(-) Hypertension
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) previous hospitalizations
(-) surgery
(-) blood transfusion
Family History
(+) Hypertension - father
(+) Diabetes Mellitus- father
(-) Bronchial Asthma
(-) thyroid diseases
Personal and Social History
Nonsmoker
Nonalcoholic beverage drinker
No known allergies to food and medications
No food preferences, regularly drinks 1 cup of
coffee per day.
OBGYN History
G0
LMP: Feb 2020
On IUD since 2019
Review of Systems
Constitutional (-) fever (-) weight loss (-) loss of appetite
HEENT (+) headaches (-) dizziness (-) blurring of vision (-) diff swallowing
Chest & Lungs (-) cough (-) colds (-) difficulty of breathing
Cardiovascular (+) palpitations (-) chest pain (-) easy fatigability (-) orthopnea
(-) edema (-) PND
GI (+) abdominal pain (-) nausea (-) vomiting (-) diarrhea
(-) constipation (-) melena (-) hematochezia
GUT (-) dysuria (-) flank pain (-) hematuria (-) urinary frequency
Neurologic (-) slurring of speech (-) sensory deficits (-) body weakness
Hematologic (-) easy bruising (-) gum bleeding (-) nose bleeding
Endocrine (+) tremors (+) heat intolerance (-) constipation (-)
hyperdefecation
Physical Examination
Vital signs BP 110/90 HR 112 RR 20 Temp 36.5C
Antropometrics Ht 153 cm Wt 75kg BMI 32 kg/m2 (obese 1)
General survey GCS 15, coherent, oriented, follows commands
Skin Warm and moist, no hyperpigmentation
HEENT No exophthalmos, no lid retraction, no excess tearing, no
palpable neck mass, thyroid cartilage moves upon
deglutition, no cervical lymphadenopaties, nondistended
neck veins
Chest and Lungs Symmetrical chest expansion, clear breath sounds
Cardiovascular Adynamic precordium, tachycardic, regular rhythm
Abdomen Normoactive bowel sounds, soft, nontender abdomen
Extremities Full equal pulses, no cyanosis, no edema, tremors
Salient Features
• 33/F
• Cc: palpitations
• No known co morbids
• No recent intake of caffeine
• (+) tremors
• (+) heat intolerance
• (+) tachycardic at 112bpm
Working Impression
Hyperthyroidism
Rule out Cardiac Dysrhythmia
33/F
PALPITATIONS
HYPERTHYROIDISM
MORE LIKELY LESS LIKELY
Rapid
heartbeat Cannot
Rule out
(+) tremors
(+) heat
intolerance
DIFFERENTIAL DIAGNOSES
33/F
PALPITATIONS
CARDIAC DYSRHYTHMIA CAFFEINE/DRUG- INDUCED ANXIETY DISORDER
MORE LIKELY LESS LIKELY MORE LIKELY LESS LIKELY MORE LIKELY LESS LIKELY
Rapid No fatigue, Regular coffee No recent Rapid No known
heartbeat dizziness, intake intake of heartbeat emotional
shortness of caffeine, cough response or
Sudden onset breath, chest Rapid medications or Common cause stressor.
pain heartbeat stimulants of palpitations
Sinus Common cause Hormonal
tachycardia on of palpitations changes in
ECG women
AF is common
in patient >50
years old
Upon admission
Test Result Normal CBC Result Normal
iCa 1.26 N 1.12-1.32 Hgb 107 L 120-160
• Telemetry Mg 0.7 N 0.66-1.07 Hct 0.34 L 0.35-0.47
BUN 7.2 2.9-9.4 WBC 5.0 4.5-11.0
• No caffeine in Crea 33 53-115
diet Seg 46 31-76
Glucose 5.7 N 3.9-5.8
Lym 39 24-44
Na 140 N 138-146
Mon 12 2-9
K 4.3 N 3.5-4.9
• Started on Plt Ct 245 140-440
Bisoprolol 5mg Cl 107 N 98-109
MCV 86 78-100
tablet once daily BCR 53.8
eGFR 140
MCH 28 27-34
• Referred to MCHC 319 320-360
HS Trop I <1.5 N 0.0-18.9
Endo service
ALP 56 N 40-150
• started with ALT 18.8 N 0.0-55.0
Methimazole
20mg tablet 2
Test Result Normal
times a day, TSH 0.05 L 0.27-3.75
• Shifted to FT3 58.39 H 4.2-12.0
Propranolol FT4 110.38 H 8.8-33.0
40mg tablet
twice daily
Ejection Fraction: 79%
Normal left ventricular size,
systolic and diastolic
function.
Normal left atrial size,
pressure and volume index.
Minimal pericardial effusion.
Normal heart valves.
Normal pulmonary artery
pressure.
Sinus tachycardia
Normal Sinus
Rhythm
No active lung parenchymal infiltrates.
Pulmonary vessels are not dilated.
Heart is not enlarged. Aorta is unremarkable.
Trachea is midline.
Costophrenic sulcus and hemidiaphragm are
intact.
Persistent slight rightward curvature of the
spine.
Impression:
Unremarkable cardiopulmonary findings.
Consider mild thoracic dextroscoliosis
FIRST
HOSPITAL DAY Urinalysis Result Normal
color yellow
transparency turbid
• Still with
palpitations glucose negative
• Methimazole 20mg bilirubin negative
tablet was increased ketone negative
to 3 times a day. Sp. gravity 1.025
• Propranolol 40mg blood trace
tablet twice daily pH 5.5
was continued.
protein negative
urobilinogen 3.2
• Epigastric pain noted nitrite positive
leucocyte negative
• Pantoprazole 40mg
RBC 106 0.0-13.3
IV was given once
daily. WBC 56.6 0.0-16.1
• Urinalysis was also Epithelial 65.3 0.0-25.6
cells
done, bacteuria was
noted and was bacteria 11900.2 0.0-209.4
started on
Cefuroxime 500mg
tablet 2x daily.
SECOND THIRD
HOSPITAL DAY HOSPITAL DAY
•still with •still with CBC Result prev Normal
palpitations palpitations Hgb 96 L 107 L 120-160
•noted fever of Hct 0.29 L 0.34 L 0.35-0.47
•Methimazole was
increased to every Tmax 38’C and WBC 7.1 5.0 4.5-11.0
6 hours. epigastric pain, no Seg 54 46 31-76
nausea and Lym 34 39 24-44
•Abdominal pain vomiting Mon 9 12 2-9
was improved. No •Propranolol 20mg Plt Ct 218 245 140-440
other signs and
symptoms noted. every 4 hrs MCV 83 N 86 78-100
•started MCH 27 N 28 27-34
Hydrocortisone MCHC 329 N 319 320-360
100mg IV now then Procalcitonin <0.05
50mg IV every 6 Urine CS:
[Link] ESBL negative
hours. Susceptible to
•Cefuroxime was Cefuroxime, Ampicillin, Amoxicillin-Clavulanate,
Trimethophrim-Sulfamethoxazole, Gentamicin,
also shifted to Nitrofurantoin
Ceftriaxone 2g IV
once daily.
FIRST SECOND THIRD FOURTH
HOSPITAL DAY HOSPITAL DAY HOSPITAL DAY HOSPITAL DAY
• Still with •still with •still with •Patient became
palpitations palpitations palpitations afebrile, resolution
• Methimazole 20mg •noted fever of of palpitations and
tablet was increased •Methimazole was
increased to every Tmax 38’C and epigastric pain
to 3 times a day.
6 hours. epigastric pain, no were noted,
• Propranolol 40mg
tablet twice daily nausea and continuation of in-
was continued. •Abdominal pain vomiting patient medical
was improved. No •started
other signs and management was
• Epigastric pain noted symptoms noted. Hydrocortisone still advised but
100mg IV now then patient opted to be
• Pantoprazole 40mg 50mg IV every 6 discharged against
IV was given once hours. medical advise.
daily. •Cefuroxime was
• Urinalysis was also also shifted to
done, bacteuria was
noted and was
Ceftriaxone 2g IV
started on once daily.
Cefuroxime 500mg
tablet 2x daily.
DAMA
Sent home with the
ff meds:
•Methimazole
20mg tab q6
•Propranolol 40mg
tab q8
•Cefixime 200mg
bid x 7 days
•Repeat TSH, FT3,
FT4 in 2 weeks
Final Diagnosis
Hyperthyroidism
Acute uncomplicated cystitis
HYPERTHYROIDISM
• excess synthesis and secretion of
thyroid hormones by the thyroid
gland.
• ↑ FT3
• ↑ FT4
• Thyrotoxicosis - state of thyroid hormone excess.
• Hyperthyroidism- result of excessive thyroid function
Harrison’s Principles of Internal Medicine 20th ed. Chapter 377
SIGNS AND SYMPTOMS
Harrison’s Principles of Internal Medicine 20 ed. p.2703
2016 American Thyroid Association Guidelines for Diagnosis and
Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
DIAGNOSIS
↑ FT3
↑ FT4 Overactive thyroid gland
↓ TSH
↑ Thyrotropin receptor
Grave’s disease
antibodies (TRAbs)
Thyroid scan toxic nodular goiter
or thyroiditis
TREATMENT
• 2016 American Thyroid Association (ATA)
hyperthyroidism/ thyrotoxicosis guidelines
Beta-adrenergic blockade
Radioactive iodine therapy
Antithyroid drugs
Thyroidectomy
Beta-adrenergic blockade
2016 American Thyroid Association hyperthyroidism/
thyrotoxicosis Guidelines
Radioactive Iodine Therapy
• radioactive iodine
destroys the cells that
have taken it up.
• The result is that the
thyroid or thyroid
nodules shrink in size,
and the level of thyroid
hormone in the blood
returns to normal.
Antithyroid drugs
• If methimazole is chosen as the primary
therapy for Graves disease, the
medication should be continued for
approximately 12-18 months and then
discontinued if the serum thyrotropin and
thyrotropin receptor antibody levels are
normal at that time.
2016 American Thyroid Association hyperthyroidism/
thyrotoxicosis Guidelines
Thyroidectomy
• If surgery is chosen as the primary therapy for
Graves disease, near-total or total thyroidectomy
is the procedure of choice
• If surgery is chosen as treatment for toxic
multinodular goiter, near-total or total
thyroidectomy should be performed
• If surgery is chosen as the treatment for toxic
adenoma, a thyroid sonogram should be done to
evaluate the entire thyroid gland; an ipsilateral
thyroid lobectomy (or isthmusectomy, if the
adenoma is in the thyroid isthmus), should be
performed for isolated toxic adenomas
Prevalance of Hyperthyroidism in the
Philippines
• PhilTiDeS is a survey on the prevalence of both goiters
and thyroid disorders in the Philippines
The Philippine Thyroid Diseases Study (PhilTiDeS 1): Prevalence
of Thyroid Disorders Among Adults in the Philippines
DIFFERENTIALS
Palpitations
DIAGNOSTICS
•Drug-induced
•Cardiac dysrhythmia
ECG: sinus
•Anxiety disorder
tachycardia
Burch and
TSH LOW Wartofsky Score
PROFILE FT3 FT4 HIGH (+) fever 40
Palpitations
33/F (+) tremors
(+) heat Impending thyroid
(+) tremors HYPERTHYROIDISM intolerance storm
(+) heat (+) tachycardic
intolerance
(+) tachycardic Anti-thyroid drug
Beta blocker
TREATMENT Hydrocortisone 100mg IV
now then 50mg IV every 6
hours
LEARNING POINTS
• History and Physical examination are important in the
diagnosis of hyperthyroidism
• Etiology of thyrotoxicosis should be determined.
• Beta-adrenergic blockade is recommended in all
patients with symptomatic thyrotoxicosis.
Thank you!
