Medical English case 2

A 27-years woman present to your office complaining of progressing nervousness,

Fatigue, palpitation, and the recent development of a resting hand tremor. She also
States that she is having difficulty concentrating at work and has been more irritable
with her coworkers. The patient also notes that she has developed a persistent rash
over her shins that has not improved with the use of topical steroid creams. All of her
symptoms have come on gradually over the past few months and continue get
worse. Review of systems also reveals an unintentional weight loss of about 10 lb,
insomnia, and amenorrhea for the past 2 months (the patiens menstrual cycles are
usually quite regular). The patient past medical stories has unremarkable and she
takes no oral medications. She is currently not sexually active and does not drink
alcohol, smoke, or use any illicit drugs. On examinations, she is afebrile. Her pulse
varles from 70 to 110 beats/min. She appears restless and anxious. Her skin is warm
and moist. Her eyes show evidence of exophtalmous and lid retraction bilaterally,
although, funduscopic examination is normal. Neck examination reveals symmetric
thyroid enlargement, without any discrete palpable masses. Cardiac examination
reveals an irregular rhytm. Her lungs are clear to auscultation.extremity examination
Reveals an erymathous, thickened rash on both shins, neurologic examination is
normal except for a fine resting tremor in her hands when she attemps to hold out
her outstretched arms. Initial lab a negative pregnancy test and an undetectable
levels of thyroid-stimulating system (TSH).

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KEYWORDS

1. A 27 years old woman

2. Progressing nervousness, fatigue, palpitation
3. The recent development of a resting had tremor
4. Having difficulty concentrating at work
5. Has been more irritable with her coworkers
6. Has developed a persistent rash over her shins.
7. All of her symtomps continue to get worse.
8. Has unintentional weight loss of about 10 lb, insomnia, and amenorrhea for
the past2 months
9. On examinations, she is afebrile, pulse varies, appears restless and axious,
skin is warm and moist
10. Her eyes show evidence of exophtalmous and lid retraction bilaterally
11. Neck examination reveals symmetric thryroid enlargement
12. Cardiac examination reveals an irregular rhytm
13. Her lungs are clear to auscultation.
14. Extremity examination reveals an erythematous, thickened rash on both shins

PROBLEM

A 27 years old woman present to your office complaining of progressing

nervousness, fatigue, palpitation, and the recent development of a resting hand
tremor.

DIFFERENTIAL DIAGNOSE

Anxiety Disorders
Panic Attack
Grave Disease

DIAGNOSE

GRAVE DISEASE

LEARNING ISSUE:
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DEFINITION

What Is Graves' Disease?

First described by Sir Robert Graves in the early 19th century, Graves disease is one of
the most common of all thyroid problems.

It is also the leading cause of hyperthyroidism, a condition in which the thyroid gland
produces excessive hormones.

Once the disorder has been correctly diagnosed, it is quite easy to treat. In some cases,
Graves' disease goes into remission or disappears completely after several months or
years. Left untreated, however, it can lead to serious complications -- even death.

Although the symptoms can cause discomfort, Graves' disease generally has no long-
term adverse health consequences if the patient receives prompt and proper medical
care.

SYMPTOMS AND CLINICAL MANIFESTATION

Hyperthyroidism

The majority of symptoms of Graves disease are caused by the excessive

production of thyroid hormones by the thyroid gland (see Hyperthyroidism brochure).
These may include, but are not limited to, racing heartbeat, hand tremors, trouble
sleeping, weight loss, muscle weakness, neuropsychiatric symptoms and heat
intolerance.

Eye disease

Graves disease is the only kind of hyperthyroidism that can be associated with
inflammation of the eyes, swelling of the tissues around the eyes and bulging of the
eyes (called Graves ophthalmopathy or orbitopathy). Overall, a third of patients with
Graves disease develop some signs and symptoms of Graves eye disease but only
5% have moderate-to-severe inflammation of the eye tissues to cause serious or
permanent vision trouble. Patients who have any suggestion of eye symptoms
should seek an evaluation with an eye doctor (an ophthalmologist) as well as their
endocrinologist. Eye symptoms most often begin about six months before or after the
diagnosis of Graves disease has been made. Seldom do eye problems occur long
after the disease has been treated. In some patients with eye symptoms,
hyperthyroidism never develops and, rarely, patients may be hypothyroid. The
severity of the eye symptoms is not related to the severity of the
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hyperthyroidism. Early signs of trouble might be red or inflamed eyes, a
bulging of the eyes due to inflammation of the tissues behind the eyeball or double
vision. Diminished vision or double vision are rare problems that usually occur later,
if at all. We do not know why, but problems with the eyes occur much more often and
are more severe in people with Graves disease who smoke cigarettes.

Skin disease

Rarely, patients with Graves disease develop a lumpy reddish thickening of the skin
in front of the shins known as pretibial myxedema (called Graves dermopathy). This
skin condition is usually painless and relatively mild, but it can be painful for some.
Like the eye trouble of Graves disease, the skin problem does not necessarily begin
precisely when the hyperthyroidism starts. Its severity is not related to the level of
thyroid hormone.
Weight loss despite increased appetite
Faster heart rate, higher blood pressure, and increased nervousness

Excessive perspiration

Increased sensitivity to heat

More frequent bowel movements

Muscle weakness, trembling hands

Development of a goiter (enlargement of the thyroid gland, causing a swelling at

the base of the neck).

Bulging eyes

Reddish, thickened, and lumpy skin in front of the shins

RISK FACTOR OF GRAVE DISEASE

Although anyone can develop Graves' disease, a number of factors can increase the
risk of disease. These risk factors include the following:

Family history. Because a family history of Graves' disease is a known risk

factor, there is likely a gene or genes that can make a person more susceptible
to the disorder.

Gender. Women are much more likely to develop Graves' disease than are
men.

Age. Graves' disease usually develops in people younger than 40.

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 Other autoimmune disorders. People with other disorders of the immune
system, such as type 1 diabetes or rheumatoid arthritis, have an increased risk.

Emotional or physical stress. Stressful life events or illness may act as a

trigger for the onset of Graves' disease among people who are genetically
susceptible.

Pregnancy. Pregnancy or recent childbirth may increase the risk of the

disorder, particularly among women who are genetically susceptible.

Smoking. Cigarette smoking, which can affect the immune system, increases
the risk of Graves' disease. Smokers who have Graves' disease are also at
increased risk of developing Graves' ophthalmopathy.

COMPLICATION
If Graves' disease isn't treated, it can cause complications, such as:

Heart disorders: In some people, the disease can cause heart rhythm
problems or heart failure.

Thyroid storm: This life-threatening complication of Graves' disease involves a

sudden increase in thyroid hormones.

A thyroid storm is a rare event, but it can result in heart failure and pulmonary
edema (a buildup of fluid in the lungs).

In the event of a thyroid storm, immediate medical attention is required.

Pregnancy problems: Miscarriage, preterm birth, fetal thyroid dysfunction,

maternal heart failure, and preeclampsia (high blood pressure during
pregnancy) are all possible complications of Graves' disease.

Brittle bones: Graves' disease can lead to osteoporosis , a condition

characterized by weak, porous bones.

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