CASE PRESENTATION AND

DISCUSSION
ON
HYPERTHYROIDISM
JHAYNUR-REZZA A. BALAHIM
General Data:
NAME: E.T,
AGE: 50 year-old
SEX: female
OCCUPATION: housewife
ADDRESS: Malagutay, Zamboanga city
RELIGION: Roman CatholiC
Chief complaint:
Vomiting
HISTORY OF PRESENT ILLNESS
 Patient is a known hyperthyroidism patient but is non-
compliant to maintenance medications such as methimazole
and propanol.
 Few Hours PTC, patient experienced sudden onset of post-
prandial vomiting (5 episodes) amounting to approximately
1 cup consisting of previously ingested food per episode.
This was associated with undocumented fever and dizziness.
Persistence of symptoms prompted consult. Denies any
chest pain, LBM and dyspnea.
PAST MEDICAL HISTORY:
 Patient is a known Hyperthyroidism patient since
2018, and is prescribed with methimazole and
propanol as maintenance medication but with poor
compliance. She is non-Hypertensive and non-
Diabetic. She was previously admitted at 2018 due
to hyperthyroidism. With no history of previous
surgery. No known allergies to food and
medications.
OB HISTORY
 menarche at age 14
 menopause at 48 years-old.
 She claims to have had regular menses every month
consuming 2-3 pads per day for 4 days before her
menopause.
 With an obstetric score of G7P7 (7007).
PERSONAL & SOCIAL HISTORY
 denies any history of cigarette smoking, alcoholic
beverage consumption and illicit drug use.
 a Housewife and lives with her 7 children and
husband.
 Her diet consists of fish, vegetables and rice.
Pertinent ROS:
 (+) weight loss
 (+) Heat intolerance
 (+) palpitation
 (-) cough
 (-) DOB
PHYSICAL EXAMINATION
 General: Awake, Coherent,Weak-looking and Agitated but
Not in respiratory Distress
 Vital Signs: Temp: 38°C BP: 120/80 mmHg
PR: 140 bpm SpO2:98% (room air)
RR: 24 cpm Weight: 49 Kg
 HEENT: Atraumatic head; Anicteric sclerae, pink
palpebral conjunctiva, exophthalmos; no ear
deformities or tenderness; no alar flaring; Diffuse
anterior neck mass, smooth, nontender and moves
with deglutition, measuring about 4x5cm
 Chest/lungs: Equal chest expansion, no tenderness
on palpation, Clear breath sounds
 Cardiovascular: Adynamic precordium; No Heaves
and Thrills; Tachycardic but regular rhythm, no
murmurs noted
 Abdomen: Soft, flat abdomen; Normoactive bowel
sounds; non-tender on all quadrants.
 Extremities: good peripheral pulses; CRT <2seconds;
(+) tremors
 Neurologic: Alert and Oriented to 3 spheres; no
Motor weakness or sensory deficits noted;
Clinical Diagnosis:
Thyroid Storm
(Primary Diagnosis)
 Cues/Basis:
 + History of Hyperthyroidism and poor compliance to
medications
 + Burch-Wartofsky score: 65 pts
 [ PR of 140 (25 pts), Temp of 38°C (10), Agitation
(10), vomiting(10), Precipitant History(10)]
Hyperthyroidism secondary to grave’s
disease (Secondary Diagnosis)

 + Heat intolerance, Palpitations, Weight loss, tachycardia, diffused Neck

Paraclinical diagnostic procedures
  benefit risk Cost availability

FT4, TSH For comparison or as baseline to evaluate Low risk 530 and 600 Available at ZCMC

management (total: 1130)

ECG Assessment of Cardiac activity, look for Low risk Free (ER-ZCMC); Available at ZCMC

atrial fibrillation  

CBC As baseline and to look for leukocytosis Low risk 175 Available at ZCMC

(infection

LFTs (AST/ALT ,Albumin) Liver function derangements may be Low risk 290 Available at ZCMC

present in Thyroid storm

Treatment
Pretreatment diagnosis:
Thyroid storm secondary to Hyperthyroidism prob secondary to Grave’s disease
Goals of treatment for primary diagnosis
 Stop synthesis of new thyroid hormones
 Halt release of preformed thyroid hormones
 Prevent conversion of T4 to T3
 Control adrenergic symptoms associated with thyrotoxicosis
 Control systemic decompensation
 Treat underlying cause
treatment modality
 PTU 500-1000mg loading dose and 250mg every 4 hours per orem (as inpatient) or
Methimazole 60-80mg/day (upon discharge)
 Lugol’s solution 4-8 drops per orem every 6-8hours
 Propranolol 60-80mg per orem every 4 hours
 Paracetamol 500mg every 4 hours for fever and pain

How to evaluate result or outcome

 Repeat FT4,TSH and CBC for comparison with Baseline
 Reduction/ alleviated symptoms
Prevention and Health Promotion
Final diagnosis: : Thyroid storm secondary to Hyperthyroidism prob
secondary to Grave’s disease

Describe how you will advise patient on prevention of disease and

health promotion
 - advise patient on strict compliance with maintenance medication
and of follow-up checkups
 - advice patient and significant others on early detection of symptoms
of thyroid storm such as fever, palpitations, agitation, diarrhea and
vomiting