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

Medical Grand Rounds Clinical Vignette December 3, 2008 Steven Giovannone, MD. Chief Complaint. A 42 year old female presents to the emergency room with palpitations for 1 week. History of Present Illness.

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

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  1. Medical Grand Rounds Clinical Vignette December 3, 2008Steven 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: Hyperreflexivepatellar 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 XRaywas 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

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