SAN BEDA UNIVERSITY

College of Medicine

IM-2 (INTERNAL MEDICINE 2) Written Report

Name of Interviewer: John Gabriel C. Milla Group D2

YL 3

Date and Time of Interview: August 17, 2021

General Data: R.N, 35-year-old male born on January 19, 1987 residing in Navotas, single Roman
Catholic

Chief Complaint: Increased blood pressure

History of Present Illness:

One month prior to consult his blood pressure increased from 140/90 to 160/90 mmHg which is his
highest and was sent home from work. It usually happens suddenly even at rest but does not go to the
clinic due to time constraints. It is accompanied by palpitations which the patient tries relieving by resting
and drinking water, but it did not help. After a few days he visited the clinic 3 times while at work but was
not prescribed with medicine. The patient works as a call center agent in the night shift from 10pm-8am
with 1 hour break with no rest and drinks coffee.

2 days prior to consultation his increased blood pressure and palpitations is now accompanied with
sudden dizziness, weakness and difficulty sleeping. His dizziness is characterized by lightheadedness
with accompanying fatigue and no headache. The patient feels he is fatigued all the time and wants to sit
down with accompanying weakness. The patient tries to rest to alleviate the symptoms. His difficulty in
sleeping is due to his palpitations, he sleeps during the morning which he also has difficulty. The patient
has no accompanying symptoms of seizures and difficulty of breathing.

Past Medical History:

The patient has no childhood illnesses throughout life, has no tuberculosis, no diabetes and no
hypertension. He has completed his childhood vaccinations, his recent vaccine was for Covid-19
Astrazeneca brand, his first dose was administered last January 26, 2022 and second dose at February
23,2022. He has no exposure to Covid-19, no hospitalizations, no surgeries, no medications and no
allergies
Personal and Social History:
 The patient started smoking when he was 16 y/o with half a pack a day. The pack years is 9.5
 Drinks occasionally for 2-3 bottles a week of red horse beer
 Currently works as a call center agent at night shift 10pm-8am.
 Lives near the road with his parents. His house is made up of wood and cement. It has 3 floors and
lives near the river
 His meals consist of fish and vegetables eats 3-4x a day and drinks coffee often. The patient
experiences loss of appetite that he states his pants are loosening
 Garbage disposal- collection
 No illegal drugs
 Sexual history- not sexually active, no contraceptives and condoms used

Family History:
The patient’s mother 72 y/o was diagnosed with goiter. The father was 70 y/o diagnosed with high blood
and cardiac problems, takes maintenance drugs everyday. His …is 39 y/o and was diagnosed with goiter
last 2021 unrecalled medications.

Review of Systems:
General: (+) weight loss, (+) fatigue, (+) changes in sleep pattern, (+) loss of appetite
Skin: (-) rashes, (-) lesions, (-) dryness, (-) changes in skin color, (-) excessive sweating
Head: (-) headache, (-) head injury
Eyes: (-) blurring of vision, (-) eye itchiness (-) dimming of vision
Ears: (-) tinnitus, (-) changes in hearing, (-) ear pain, (-) redness
Nose: (-) epistaxis, (-) nasal discharge, (-) changes in smell,
Neck/Throat: (-) sore throat, (-) neck mass, (-) difficulty swallowing
Respiratory: (-) cough, (-) dyspnea, (-) edema, (-) difficulty breathing
Cardiovascular: (+) occasional chest pain, (-) orthopnea, (+) palpitations
Gastrointestinal: (-) abdominal pain, (-) vomiting, (-) diarrhea, (-) bloody stools
Genitourinary: (-) dysuria, (-) changes in urine character or amount,
Musculoskeletal: (-) joint pain or swelling
Endocrine: (+) heat intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia

PHYSICAL EXAMINATION

General Survey: conscious, coherent, anxioius-looking

Vital Signs: BP=160/90 HR=110/min RR=22/min T=37.5C
 BMI:21.3 kg/m2 Ht: 168cm Wt: 60 kg
HEENT: pink palpebral conjunctivae, anicteric sclerae, (-) cervical lymphadenopathy, no neck mass, no
neck vein engorgement, (+) exophthalmos
Lungs: Equal chest expansion, no retractions, clear breath sounds
Cardiac: (-) heaves/thrills, AB a t 5th LICS MCL, S1 > S2 at apex, (-) S3/S4, no murmurs
Abdomen: soft abdomen, NABS, non-tender liver and spleen not palpable
Extremities: (-) edema, (+) finger tremors

INTERPRETATIVE SUMMARY

The patient is a 35 y/o male who works as a call center agent complains of sudden onset increase in
blood pressure which one month prior to consult it increased from 140/90 to 160/90 mmHg. It is
accompanied with sudden onset of palpitations which at first is relieved by drinking water and rest but
after a few days it did not help. He had check-up 3 times at the company clinic where he works and was
not prescribed of any medications. Two days prior to consult the patient experiences the same symptoms
but it is additionally accompanied with sudden onset of lightheadedness and easy fatigability. He has a
family history of goiter from his mother and sibling and his father has hypertension. In his occupation, he
works on the night shift from 10pm-8am with only 1 hour break and drinks coffee. The patient also noted
that he has unintended weight loss. His physical exam shows that he is anxious looking, has
exophthalmos and finger tremors which is consistent with hyperthyroidism

DIAGNOSIS
Primary Working Impression: Thyrotoxicosis t/c Graves’ Disease
Differentials: Diffuse nontoxic goiter
Acute Thyroiditis
Primary aldosteronism

Secondary Diagnosis/Co-morbidities: Stage II Hypertension

DISCUSSION

This patient is most likely having thyrotoxicosis to consider Graves’ Disease because it is
consistent with the clinical presentation of unintended weight loss, sudden onset of increased blood
pressure with palpitation and sudden onset of lightheadedness with fatigue. I also considered that it might
be Graves’ disease is the patient’s age and family history of goiter and it can cause hyperthyroidism. The
cause of increased production hormones is due to increased production of thyroid stimulating hormone by
the thyroid gland which can be detected using thyrotropin-binding immunoglobulin assay. In this case,
environmental factors play a role in the patient’s development of hyperthyroidism which are stress from
work and smoking. While smoking is a minor risk factor in the development of hyperthyroidism it plays a
role in development of exophthalmos. The symptoms are due to overproduction of thyroid hormones
which activates the RAAS pathway that increases cardiac output which causes hypertension, palpitations
and dizziness. The patient’s tremors is also due to increase stimulation of the sympathetic nervous
system and his weight loss is due to increased basal metabolic rate in hyperthyroidism.

I considered the patient having diffuse non-toxic goiter as my first differential due to the patient’s
family history of goiter however it is not specific of what type of goiter. It is most likely due to the clinical
presentation of hyperthyroidism as stated in the last paragraph such as hypertension, palpitations,

tremors and unintended weight loss. It is also sporadic due to a result of environmental or genetic factors
that do not affect the general population. However, it is less likely because the patient did not indicate in
his diet of excess iodine intake which is much more common in goiter and in physical exam there is no
thyroid enlargement present and no Pemberton’s sign which are facial flushing and dilatation of cervical
veins.

The 2nd differential is subacute thyroiditis, it is more likely because the presentation of
hyperthyroidism of the patient however it is less likely because the patient does not have a history of viral
infection, and his physical exam did not elicit presence of asymmetrically enlarged, firm, and tender
thyroid gland.

The last differential for this case would be primary aldosteronism which is more likely due to
presence of hypokalemia via easy fatigability and increased blood pressure of the patient. The
symptom of the patient is due to overproduction of aldosterone which activated the RAAS system.
However, it is less likely because the patient did not present with muscle weakness, no polydipsia and
no polyuria.

PROBLEM LIST and MANAGEMENT PLAN

1) Grave’s disease
Diagnostics:
 Serum TSH and unbound T4- sensitive marker for thyrotoxicosis. Thyrotoxicosis is
diagnosed when TSH is low and T4 is high
 Thyroid radioiodine- to check for increase of iodine levels
 ECG- To check heart rhythm and electrical patterns
 Thyrotropin-binding immunoglobulin assay- to diagnose Graves disease
Therapeutics:
  Propanolol (20-40 mg every 6 hours) may be used at the start of treatment to control
adrenergic symptoms until euthyroidism is reached.
 Thyroid function tests should be done 3-4 weeks after initiation of treatment
 Methimazole or carbimazole: 10-20 mg, 2-3x/day initially, then titrated to 2.5-10 mg per
day. First line agent of hyperthyroidism
 Propylthiouracil (PTU): 100-200 mg every 8 hours initially, then titrated to 50 mg once
or twice a day. Preferred drug for individuals with thyrotoxicosis
 Advise patient to reduce stress from work by taking breaks in between
 Monitory blood pressure
 Advise patient to cease smoking

3) Smoking – Educate the patient on the harmful effects of smoking and encourage the patient to stop

PERSONAL REFLECTIONS:
1) Please rank the following components for this activity from 1-5 (with 1 being the easiest, 5 hardest):

bedside history-taking and physical exam - 1

discussion of differential diagnosis - 5
generating problem list and plan - 4
organizing case presentation - 2
organizing written report - 3

2) What made your #1 activity easy? What made your #5 activity difficult?
- It was easy because the patient was cooperative, and the physical exam was straightforward in its
findings. However, I find it difficult to discuss the differentials due to difficulty in correlating the symptoms
of the patient to the disease.

2) What improvements can you make for your performance in the next activity?
- To be able to explain the pathophysiology of the differential diagnosis properly and to correlate it to the
case. To learn how to generate a problem list and plan properly.