1. Weight loss ERWEB case

2. History A 45-year-old lady attends surgery with a three months history of hot sweats, palpitations, tremor and weight loss of 1 stone. Also having diarrhoea She has no significant past medical history and is on no treatment.

3. What are the possible causes of her symptoms?

4. 1.Thyrotoxicosis

5. What are the possible causes of her symptoms? 1.Thyrotoxicosis 2.Anxiety neurosis

6. What are the possible causes of her symptoms? 1.Thyrotoxicosis 2.Anxiety neurosis 3.Lymphoma – but palpitations and tremor less likely

7. What are the possible causes of her symptoms? 1.Thyrotoxicosis 2.Anxiety neurosis 3.Lymphoma – but palpitations and tremor less likely 4.Colitis

8. What are the possible causes of her symptoms? 1.Thyrotoxicosis 2.Anxiety neurosis 3.Lymphoma – but palpitations and tremor less likely 4.Colitis 5.Carcinoid – but rare – also flushing and wheezing

9. What other symptoms might have been produced by this disorder?

10. 1.Hair loss 2.Swelling in neck 3.Anxiety 4.Amenorrhea 5.Tiredness

11. What might you find on examination?

13. Graves’ eye disease Heavy lymphocytic infiltrate Compresses optic nerve Not related to degree of thyrotoxicosis Treatment High dose steroids Surgical decompression

14. Eye disease Exopthalmos Proptosis Risk of blindness as optic nerve compressed

15. Goitre

16. Palmar erythema

17. Tachycardia

18. Proximal myopathy Test by standing from seated position with arms folded…

19. Pre-tibial myxoedema

20. Other auto-immune conditions

21. What tests could you perform to confirm the presence of an endocrine disorder?

22. 1.TSH (less that 0.03) 2.T3/T4 Free T4 > 30 symptomatic Free T4 >100 v. symptomatic 3.Thyroid auto-antibodies

23. What is the aetiology of this disorder?

24. 1.Graves’s disease autoimmune disease associated with thyroid stimulating antibodies 2.Toxic multi nodular goitre 3.Toxic adenoma 4.Drugs 5.Post-partum thyroiditis 6.Sub acute thyroiditis

25. Natural history of Graves’ disease

26. . What are the possible treatment options and what are the side effects?

27. Drugs –Carbimazole –Propylthiouracil

28. . What are the possible treatment options and what are the side effects? Drugs –Carbimazole –Propylthiouracil Radio iodine

29. . What are the possible treatment options and what are the side effects? Drugs –Carbimazole –Propylthiouracil Radio iodine Surgery

30. Side effects Drug rash Agranulocytosis idiosyncratic

31. How do you titrate drugs? Either Titrate to biochemistry Or Block and replace

32. What if you don’t treat… High output cardiac failure and death Atrial fibrillation Amenorrhea Thyrotoxic storm –associated with superadded infection/illness Osteoporosis Some people feel great – some go mad (or drive their families mad)

33. She thinks she may be six weeks pregnant. How does this affect your choice of treatment?

34. Is she really! Not radio iodine Surgery not recommended Carbimazole will cross placenta and make baby hypothyroid So use lowest dose propylthiouracil possible

35. She asks you if there is any chance the baby might have the same disorder. What would you tell her?

36. Measure thyroid stimulating antibodies Monitor foetus –signs growth retardation –foetal heart rate – tachycardic? Consider treating with carbimazole if signs foetus thyrotoxic