RG is a 40 year old white divorced male electrician who presents for further evaluation and treatment of his Grave's disease.
HPI: The patient was in his usual state of excellent health until 1996 when he presented with blurred vision. Thyroid function was tested at that time and was normal according to the patient. In 1998 the patient experienced changes in his personality with mood changes and emotional lability which resulted in a divorce. In early 1999 the patient presented with headaches, insomnia, a 25 pound weight loss, palpitations and increase frequency of bowel movements. The results of the thyroid function tests and treatment initiated are noted in the table below.
| DATE | TSH | T4 | FT4I | T3 | COMMENTS |
| µU/ml (.4-5.5) |
µg/dl (4.5-12.5) |
units (1.4-3.8) |
ng/m (70-140) |
||
| 8/98 | 2.5 | 13.9 | 4.5 | ||
| 11/98 | 2.5 | 11.4 | 4.7 | Insomnia/palpitations | |
| 1/99 | 2.0 | 14.7 | 5.9 | 25 lb. weight loss | |
| 3/99 | 1.2 | 3.3 | 153 | Tapazole 10 mg TID | |
| 4/99 | 2.8 | 16 | 6.6 | Off Tapazole,7 days* | |
| 5/99 | 2.1 | 14.8 | 6.1 | Off Tapazole,14 days |
*I-123 uptake was 50% at 24 hours; TBG normal
Symptoms worsened and Tapazole was restarted at 10 mg BID. The patient was referred to an academic medical center for management of Graves Disease refractory to antithyroid treatment.
| PMHx: | Hypertension, well controlled for many years |
| Surgical repair of a horseshoe kidney at age 21 years
|
| MEDS: | Tapazole 10 mg BID |
| Propranolol XL 120 mg QD | |
| Hydrochlorathiazide 50 mg QD | |
| Norvasc 5 mg QD |
FSHX: Patient has one 8 year old daughter with his first wife. No family history is available because the patient is adopted.
PEX: Blood pressure 150/86; Heart rate 80/min, regular; Respiratory rate 12/min; Temperature 36.7, Weight 105.6 Kg. There was no exophthalmos, stare or lid lag. There was a 30 gm diffuse goiter with a palpable pyramidal lobe. The thyroid did not have any nodules or bruits. There was no associated neck adenopathy. The pulmonary and cardiovascular exams were entirely normal. The abdominal exam was unremarkable as were his neurological and skin exams.
LABS: Repeat thyroid tests were performed while the patient was taking Tapazole 10 mg BID:
| Test | Result | Normal Range |
| Thyroxine | 14.5 µg/dl | 5.0-11.6 |
| Free Thyroxine Index | 16.5 units | 6-10.5 |
| Triiodothyroinine | 192 ng/dl | 80-195 |
| Thyrotropin | 10µU/ml | 0.3-3.8 |
| Thyroglobulin | 72 ng/ml | <40 |
| Anti microsomal ab | negative titer | negative |
| Anti thyroglobulin ab | negative titer | negative |
What studies would you wish to obtain at this point: