Hyperthyroidism

History Taking

Chief Complaint:

• Feeling restless and anxious

• Unintentional weight loss despite increased appetite

• Complains of palpitations, or unusually fast heart rate

History of Presenting Complaint:

• The patient may describe an insidious onset of symptoms over weeks to months

• Symptoms often progressive, becoming more pronounced over time

• Feeling intolerant to heat

• Sweating more than usual

• Eyes - red eyes, diplopia

• Reports frequent bowel movements

• In females, may have menstrual changes such as lighter or less frequent periods

System Review:

• Cardiovascular: Palpitations, chest discomfort, dyspnea on exertion

• Gastrointestinal: Increased frequency of bowel movements

• Dermatologic: Thin, moist, warm skin, hair loss

• Musculoskeletal: Fatigue, muscle weakness

• Neuropsychiatric: Anxiety, restlessness, insomnia, tremors

• Endocrine: Increased appetite, weight loss, heat intolerance, excessive sweating

Past Medical History:

• Previous diagnosis of autoimmune diseases (Graves' disease)

• Personal or family history of thyroid disease

• History of neck irradiation or radioactive iodine therapy

Drug History:

• History of medication use that can induce hyperthyroidism such as amiodarone or iodine-containing medications

Family History:

• Positive family history of thyroid disorders

• Family history of other autoimmune disorders

Personal History:

• Smoking history - can aggravate thyroid eye disease

• Regular exercise until recent months when fatigue and palpitations increased

Social History:

• Stable job and relationships, which have been strained due to mood changes and anxiety

Physical Examination

General Examination:

• Noticeable weight loss despite increased appetite

• Palmar erythema observed in the hands

• Fine tremor on extension of the arms

• Patient appears restless and anxious

• Lid lag and proptosis noted on facial examination

• Complex ophthalmoplegia

Cardiac Examination:

• Tachycardia noted with regular rhythm

• Palpable thrill at the left sternal border suggesting a flow murmur

Neck Examination:

• Diffusely enlarged, smooth, non-tender thyroid gland (goitre) on palpation

• Percussion - retrosternal extension

• Auscultation - bruit (thyroid and carotid)

• Lymph node examination

Neurological Examination:

• Hyperreflexia noted in the lower limbs

Additional Examination:

• Thyroid eye signs (if present) including exophthalmos (prominent eyes), conjunctival injection or chemosis (eye redness or swelling), and periorbital edema

• Ophthalmologic examination might show lid retraction, lid lag, or rarely, limited eye movements, indicating Graves' ophthalmopathy

• Pretibial myxoedema in shins

• Proximal myopathy

Investigations

Laboratory Investigations:

• Thyroid function tests: To measure levels of Thyroid Stimulating Hormone (TSH), Free Triiodothyronine (T3), and Free Thyroxine (T4). This helps confirm the diagnosis and the severity of hyperthyroidism.

• Thyroid peroxidase antibodies (TPOAb) or TSH receptor antibodies (TRAb): To evaluate for autoimmune causes like Graves' disease.

• Complete Blood Count (CBC): To rule out anemia or other hematologic conditions that can mimic or coexist with hyperthyroidism.

• Liver function tests: Hyperthyroidism can affect liver function and cause elevated liver enzymes.

• Electrolytes: Hyperthyroidism can cause changes in electrolyte balance, such as low sodium.

Imaging:

• Thyroid ultrasound: To assess the size of the thyroid and presence of nodules.

• Radioactive Iodine Uptake (RAIU) and scan: To differentiate between different causes of hyperthyroidism (Graves' disease would show diffuse uptake, while a toxic nodule would show focal uptake).

• Orbital MRI or CT: If there is evidence of Graves' ophthalmopathy with significant eye symptoms.

Other Tests:

• EKG: To evaluate for tachycardia or atrial fibrillation, which can occur in hyperthyroidism.

• DEXA scan: If patient is at risk of osteoporosis due to prolonged untreated hyperthyroidism.

Invasive:

• Fine needle aspiration (FNA): If a solitary nodule is found on ultrasound, an FNA may be required to rule out malignancy.

Management

General Management:

• Education: Explain condition, potential complications and treatment options

• Lifestyle: Advise regular exercise, balanced diet, smoking cessation, and limiting caffeine and alcohol

• Psychological support: Manage anxiety and restlessness, refer to psychologist if necessary

Medical Management:

• Beta-blockers: For symptom control, especially tachycardia and tremors (e.g., Propranolol)

• Antithyroid drugs: Methimazole or Propylthiouracil (PTU), to inhibit thyroid hormone synthesis

• Radioactive iodine: For definitive treatment, results in hypothyroidism that needs lifelong thyroid hormone replacement

• Levothyroxine: If patient becomes hypothyroid post-radioactive iodine therapy or surgery

Surgical Management:

• Thyroidectomy: Considered if patient has large goitre causing compressive symptoms, or if patient prefers this method of definitive treatment. Requires pre-operative control of hyperthyroidism with antithyroid drugs.

Other:

• Regular follow-ups: Monitor TSH, Free T4, and symptoms

• Eye care: Frequent artificial tear eye drops for dry eyes in Graves' ophthalmopathy, consider referral to an ophthalmologist for severe eye disease

• Bone health: DEXA scans for bone density, consider supplementation for osteoporosis risk