Angelique Van Eeden Case Study

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Patient Case

Patient: Angelique van Eeden
Hospital number: GP 6317 1693
Date of birth: 02/06/1981

Main complaint
33 year old female patient presents with a 3 year history of tachycardia; tremors and profuse sweating. Patient also complains of protruding eyes.
Previously diagnosed with Grave’s disease in 2013.
Received ablation therapy in 2013 but symptoms persist as well as large goitre.
Previous symptoms now improving, but patient complains of obstructive symptoms including difficulty swallowing.

History
Medical:
- RVD negative last tested 8 years ago
- Hypertensive on Rx
- Hypercholesterolemia on Rx
Medications:
- Pharmapress 10mg
- Amlodipine 10mg
- Ridaq 12.5mg
- Atenolol 50mg
- Simvastatin 10mg
Allergies:
- Penicillin
- Cephalosporin
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Diagnosis: 1
- Raised T4 & T3
- Low TSH
- Increased I131 uptake.
- Thyroid stimulating immunoglobulin positive
Histology: 1
- Macroscopic: o fleshy appearance o Absence of normal glossy look o Less colloid
- Microscopic: o diffuse hyperplasia with cylindrical epithelial cells o Smaller follicles o Papillary outgrowths.
Natural course1
- Most persist without treatment leading to further thyroid damage and a high mortality rate.
- Rarely patients may go into spontaneous remission, these patients usually lose their abnormal immunoglobulins.
Management: 1,2
- No treatment for cause; all management is targeted at symptom control.
 Drugs
- Indications 2 o Young patients o Mild hyperthyroidism, small goitre o Pregnancy (low doses) o Malignant exophthalmos o Recurrent hyperthyroidism (or I131)
- Types o Thionamides
PTU 100-200mg 8hrly until symptoms are controlled then reduced to 50mg daily o Neomercazole 10-20mg 8hrly then 5mg daily o 40% of patients go into spontaneous remission if patient has small goitre mild hyperthyroidism and a sharp drop in TSI when started on treatment; remission is anticipated.
- Complications of drug treatment: o Hypothyroidism resulting in enlarged
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o Thyroidectomy
 Only used for medically refractory Grave’s.
- Complications of surgical treatment.
 Early:
- Thyroid crisis: o Rare with good pre-op preparation. o Pronounced hyperthyroidism leading to tachycardia; fever, confusion
Rx: Sodium Iodide 0.5g in 1l saline over 8hrs Propanolol 1mg IVI per min max 5mg
- Acute post-op respiratory distress o Haematoma development leading to compression of trachea and oedema of the larynx.
Rx: open wound in ward Immediate intubation.
- Injury to recurrent laryngeal nerves.
 Late:
- Hyperparathyroidism o Rx: Long term vitamin D therapy.
 Radiotherapy (I131) 1
- Destroys local cells and suppresses hormone synthesis, only used in patients >40yrs old.
- Clinical results follow after 1 month
- Dose of 80 micro cu per gram of gland. o Complications of radiotherapy:
- 20% of patients develop hypothyroidism that may resolve over 10 years
- Malignant changes in the thyroid are theoretically possible but have never been

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