Age: 45 years

Sex: Male
D/A: 15.07.08
D/D: 20.07.08

Admission problems :
1) Diarrhoea and vomiting- 3 days
2) Fever- 3 days
3) Loss of weight (despite normal appetite)- 6 to 7 months
4) History of alternate bowel habit- > 1 year
Past History :

1) No history of Diabetes, Tuberculosis, Hypertension,

Surgery etc.
 (on admission day)

O/ Ex : No pallor, jaundice, oedema, cyanosis

Temp.- 38.4 ºC
RR- 28 / min.
Pulse- 120 /min
BP- 100 / 40 mm of Hg
Palpitation during walking
Anxious , Heat intolerance
Warm hands and fine tremor
Muscle weakness with weight loss
Pruritus ( used comb to scratch body )
Lymph node enlargement (+)
Red eyes, Fatigue

Systemic examinations did not reveal

any significant abnormality
 Enlarged Thyroid
but no bruit

Pemberton`s
sign (-)ve

Plummer`s Nail
 Exophthalmos

Lid retraction
.
(Dalrymple`s sign)

Lid lag
(Von Graefe`s sign)
Absence of wrinkling
of forehead
on sudden upward
Gazing
(Joffroy`s sign) Infrequent Blinking
(Stellwag`s sign)

Impaired convergence
of the eyes
(Mobius` sign)
• Hct. - 30 %
• TLC - 4900 /cumm
• (N) - 63 %, (L) - 30%, (M) -7%
• Total Platelet Count- 194,000/cumm
• RBS - 6.4 mmol/l

• R/S Culture - No Growth • Urine R/M/E - NAD

• Blood C/S - No Growth • S/E - Mild Hypokalemia ( k+)

X-Ray Chest X-Ray Neck
• ECG -
Sinus Tachycardia
• TSH – 00.06 uIU/ml [ ] ( 0.40 – 4.00 )
• FT-3 – 09.29 pmol/l [ ] ( 2.30 – 6.30 )
• FT-4 – 67.80 pmol/l [ ] ( 10.3 – 24.5 )

• Total Bilirubin - 04.70 umol/l [~] ( 0.01 – 19.0 )

• Alka. Phosphatase - 79.40 u/l [~] ( 30.0 – 120 )
• ALT - 51.20 u/l [ ] ( 0.01 – 41.0 )
• Gamma GT - 84.70 u/l [ ] ( 9.00 – 40.0 )
• T. Ca ++ - 02.16 mmol/l [~] ( 2.12 – 2.62 )
Iodide Transport

Organification

Coupling

Storage

Secretion
 Thyrotoxicosis
• Thyrotoxicosis
symtomatic hyperthyroxinemia
• Hyperthyroidism
overactive tissue within
thyroid gland, resulting in
overproduction and thus an
excess of circulating free
thyroid hormones
Hyperthyroidism
• Thyrotoxic crisis ( Thyroid storm)
- rare condition where mortality is 10 %
- rapid deterioration of hyperthyroidism
with hyperpyrexia, severe tachycardia,
extreme restlessness
- precipitating factor : stress, infection,
surgery in unprepared patient,
radioiodine therapy
Clinical Thyrotoxicosis:- ELEVATED free thyroid hormone
levels and suppressed TSH level

Subclinical Thyrotoxicosis:- *NORMAL free thyroid hormone

levels and suppressed TSH level

Primary T-3 Toxicosis:- *NORMAL T-4 hormone but raised

T-3 hormone and suppressed TSH level

*Normal = Usually upper part of reference range

• High radioiodine uptake • Low radioiodine uptake

Grave`s disease
Subacute thyroiditis
Toxic nodular goiter
TSH-mediated thyrotoxicosis Hashitoxicosis
Pituitary tumour
Pituitary resistance to Drug induced
thyroid hormone
Iodide
Thyroid hormone
HCG-mediated thyrotoxicosis
Hydatidiform mole
Choriocarcinoma Struma ovarii
Other HCG-secreting tumour

Factitious
Thyroid carcinoma (very rare)
 Hypothalamus
Hypothalamus
Pituitary
Pituitary 1) Graves` disease (76%)
Thyroid
Thyroid 2) Toxic multinodular goitre (14%)
3) Toxic Nodular goitre (5%)

• Low TSH Levels • High TSH Levels

Pituitary tumour
Graves` disease
Toxic nodular goiter Pituitary resistance to Thyroid
subacute thyroiditis hormone
Hashitoxicosis
Drug induced
Struma ovarii
HCG-mediated
Thyroid carcinoma ( very rare )
 • Most Common : Resolution of onycholysis
In addition
-Weight loss despite normal or increasedinappetite
the same patient 18 months later.
Amenorrhoea, Impotance
- Palpitations, Dyspnoea on exertion
Pruritus, Diplopia, Vitiligo
- Irritability, emotional lability
Atrial fibrillation,
- Diffuse
Systolic thyroid enlargement
hypertension
- Heat
Increased intolerance,
pulse pressure sweating
Pretibial myxoedema, Fatigue
- Hyperdefecation,
Exophthalmos
- Lid retraction, Lid lag
Thyroid acropachy
- Grittiness, red eyes
Plummer`s Nails
- Palmar erythema
Hyper-reflexia
- Tremor
• Thyroid Function Tests
• Radioactive Iodine Uptake
• Technetium Scintigraphy
• Others : CXR, ECG, FNAC
USG of Neck, MRI
S. Cholesterol, LFT
Blood Sugar
• Medical

• Surgical

• Radioactive Iodine
 My Colleagues

My Team Members