Faculty of Medicine and Health Sciences
Senior Medicine
SPK 4922
Case Write Up 1
Thyrotoxicosis
Name Faiz Farhan Mohd Ramli
ID 173533
SupervisorA/P Dr. Norashikin Shamsudin
Patient’s Particular
NameMuhammad Hafiy bin Mohd Zin
RN565744
Age24 years old
SexMale
EthnicityMalay
ReligionIslam
AddressSungai Chua, Kajang
Marital StatusSingle
OccupationOffice boy
Date of Admission4th April 2018
Date of Clerking5th April 2018
Chief Complaint
Mr. Hafiy, a 24-year-old, single Malay gentleman, with underlying thyroid problem for three years, presented with three days history of fever associated with vomiting and loose stools.

History of Presenting Illness
He was apparently in his usual state until three days ago when he started to have a sudden onset of fever. It was continuous throughout the day and was together with chills and rigors. No documented temperature at home. Two tablets of regular paracetamol was taken twice per day since the onset, but he claimed of no effect. The fever was associated with vomiting, cough, and loose stools.

Regarding the vomiting episode, it occurred at the same onset with the fever. Usually, 1-2 episodes of vomiting developed with last vomiting occurred just before the admission. The content was the food eaten earlier with minimal fluid. Otherwise, it was non-bilious, not stained with blood and not post-tussive in nature. He also complained of unable to tolerate oral intake due to vomiting.

Regarding the loose stool, it happened later but at the same day with the fever. Average episodes were around 6-7 times per day and each was of moderate in amount. No complaint of abdominal pain, blood or presence of mucous in the excretions. No recent outside food intake or diet changes noted.
His cough appeared concurrently with the fever. It was intermittent, lasting up to one minutes at a time, and chesty in nature. Sputum produced was greenish in colour. Otherwise, the nature and progress was maintained since the onset. There was no sick contact with family members or colleagues noted.
Besides that, he also complained of having joint and muscle pain, but this was indeterminate in nature as the course was on and off and generalized in distribution. Since the onset of the illness, he had experienced lethargy and reduce in activities done.
On further questioning, he had been suffering from symptoms of hyperthyroidism such as heat intolerance, palpitation, diaphoresis and tremors since diagnosed three years ago. It was never resolved, was claimed to be not worsening ever since and was told to be tolerable. He had loss of weight from 55kg to 45 kg recently, however was unsure of the duration of the loss. He was not compliance with the medication though.

Otherwise, there was no shortness of breath, no chest pain, no headache, he was not agitated and no loss of appetite. No skin changes, no other alterations in bowel habits except as mentioned, no history of psychiatric illness and no previous trauma to the neck. He did not have any mood swings or lability recently. No recent travel to high-risk areas, jungle trekking or water activities prior to the sickness.

A visit to KK was made before he was referred to hospital.

Past Medical and Surgical History
He had underlying hyperthyroidism, first diagnosed at Klinik Kesihatan Sungai Chua three years ago. Initially, he presented with loss of weight, palpitations, tremor and sweating for several months with swelling of the anterior neck. Anti-thyroid treatment was started and he was compliant for one year before defaulted.
He had one episode of ward admission due to thyrotoxicosis in early 2017 at Hospital Kajang. There was no ICU admission. Since discharge, he was restarted on:
Tablet carbimazole 30mg OD
Tablet propranolol 40mg BD
However, he defaulted from taking the medicine and follow up at medical outpatient department three months prior to current admission.
Otherwise, he had no prior history of hospital admission, no childhood history of exposure to imaging procedure, no other underlying illness and surgery history was insignificant. He did not have any allergy and not taking any over the counter or traditional medicine.
Family History
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All family members are healthy and do not have any known underlying illness. There is no history of hypo- or hyperthyroidism running in the family. However, his aunty has asymptomatic goitre diagnosed during her 40s. Otherwise, there is no history of diabetes mellitus, hypertension or heart disease. No history of malignancy in the family.
Social History
He is currently lives in Sungai Chua with his family in a double-storey terrace house. There is recent fogging in the area in which his neighbour contract dengue last week. Otherwise, he claimed the area is well maintained and no sight of rodents have been seen by him and his family.
He is single and works as office boy. He has been smoking for the past six years for 6-10 cigarettes per day (equivalent to 10 pack years). He is non-alcoholic and does not involve in drug abuse.
Summary
Mr. Hafiy, a 24-year-old, Malay gentleman, has underlying hyperthyroidism first diagnosed three years ago, with repeated history of defaulted treatment, presented with fever, vomiting, diarrhoea associated with fatigue and indeterminate complained of arthralgia and myalgia.
Physical Examination (One day after clerking)
General Examination
He was alert, conscious and lying supine comfortably. He was not in pain, respiratory distress or showing signs of agitation. No diaphoresis seen. Nutritional and state of hydration were adequate. He looked thin with signs of wasting.
Vital Signs
Temperature 37.8 ?C
Pulse rate 64 beats per minute with regular rhythm and normal volume
Respiratory rate 18 breaths per minute
Blood pressure 130/76 mmHg
sPO2 99% under room air
Anthropometric Values
His current weight was 45 kg. Height measurement was not taken, thus BMI was not known.

Peripheral Examination
On examination of the hands, they were moist and warm. No clubbing or nail changes seen. Fine tremors were observed bilaterally. BCG sign was noted at left arm.
On eye examination, there was no discharge, scleral was non-jaundice and conjunctival was not pale. However, there was presence of moderate bilateral exophthalmos. No ophtalmoplegia or diplopia noted. There was no sign of lid retraction, lid lag or squint.
On mouth examination, tongue was not coated. Throat was injected, but no exudates.
On examination of extremities, there was no sign of pretibial myxoedema or proximal myopathy.

Neck Examination
On inspection of the neck, there was no changes to the overlying skin, no scars and no visible pulsations. There was diffuse symmetrical swelling over anterior part of the neck. It moved with deglutition, not on protruding of the tongue. Size was measured to be of 5cm x 5cm. It was non-tender, warm, soft in consistency, had a smooth surface and non-fluctuant. Carotid artery and trachea was palpable and not deviated. Percussion was resonance over the sternum. Auscultation of both sides revealed no bruit.
Pemberton sign was not done.
Cardiovascular Examination
On inspection of the chest, there was no deformities, scar or visible pulsations. Apex beat was located at fifth intercostal space at mid-clavicular line. There was normal heart sounds with no murmurs or additional heart sounds heard.
Respiratory Examination
On inspection, chest moved symmetrically with respiration. No paradoxical breathing noted. Percussion was resonance bilaterally in all zones. Vesicular breath sound was heard and not reduced with normal flow and absence of additional sounds.
Neurological Examination
There was no positive signs elicited. Ankle reflex and knee jerk were not exaggerated.
Other systems were unremarkable.
Provisional Diagnosis
Grave thyrotoxicosis secondary to non-compliance triggered by viral infection
Points for. Points against.

Presence of symptoms of hyperthyroidism Chills and rigors
Underlying hyperthyroidism for three years No agitation
Presence of fatigue Loss of weight History of incompliance with medication and follow up Previous history of admission due to thyrotoxicosis Family history of goitre Thin appearance with presence of flesh wasting Fine tremors Moderate bilateral exophthalmos Differential Diagnosis
Dengue fever, currently in febrile phase, not in shock, with underlying hyperthyroidism
Points for. Points against.

Presence of fever associated with
Vomiting
Diarrhoea
Chills and rigors No loss of appetite
Presence of arthralgia and myalgia No skin changes
Presence of fatigue Recent dengue infection in the neighbourhood Recent fogging Subacute painless thyroiditis triggered by viral infection
Points for. Points against.

Concurrent symptoms of viral infection Rare
Presence of symptoms of hyperthyroidism Presence of fatigue Fine tremors Enlarged anterior neck swelling Investigations
Full blood count
To determine sign of infection through increase white blood cells
To determine platelet level as sign of worsening dengue fever
To detect anaemia
KK ED Flag Normal values
White cell count 3.4 3.5 Low 4 – 11 x 109/L
Platelet 82 97 Low 150-400 x 109/L
Haematocrit 49.5 50.5 Normal 38 – 51 %
Haemoglobin 16.5 16.4 Normal 13.5 – 17.7 g/dL
Decrease in white blood cell may indicate early stages of viral infection or thyroid dysfunction.

Decrease in platelets is associated with thyroid dysfunction and also dengue fever.

Thyroid function test
For suspected thyrotoxicosis
His TSH level is 0.065 U/mL which is very low. This is suggestive of hyperthyroidism.

His FT4 level is 60.65 ng/dL which is very high. This, combined with low TSH confirmed the thyrotoxicosis.

Renal profile
To assess dehydration
Urea Creatinine Potassium Sodium
6 131 4.4 42
His creatinine and urea are high. This indicate dehydration in the patient.

NS1 antigen, IgM antibody
To rule out dengue fever
No result
Thyroid ultrasound
To assess nodularity
Doppler ultrasound shows increased blood flow with Graves’ disease and low blood flow with thyroiditis.
Electrocardiography
To assess complications
His ECG revealed sinus rhythm, normal axis and non ST changes.

Treatment
He was covered with IV Maxolon 10U TDS and IV ranitidine 50U TDS for vomiting treatment.
Carbimazole 20mg BD was started in view of his hyperthyroidism.
IV drip initiated for dehydration and maintenance.

I/O chart was prepared.

Tablet propranolol was kept in view and planned to give after dengue fever was ruled out.

Discussion
Main issue in Mr. Hafiy is his inability to stick with current regime of medicine. This non-adherence to treatment had costed him admission in the past due to complication such as in early 2017. By tackling this problem, he might avoid future admission and impending complications from happening. Hence, the direct approach to overcome the non-adherence is actually by trying to ask the patient itself on why he/she is non-adherence albeit in problem-solving and non-judgemental manner.

The patients may open up their problems with the physician and simply solved the issue. Nevertheless, in this case, Mr. Hafiy is a young adult and according to study this is common due to ‘rebellious stage’ they are in to have a ‘free’ life, that is not being restricted to particular matter. In this situation, it is adherence to thyroid medication drugs daily.

Among the approach that can be taken include to create an understanding between the physician and Mr. Hafiy regarding his health status. He need to know what is thyrotoxicosis and why it can happen. Thyrotoxicosis is a clinical state in which there is a high action of thyroid hormone in the tissue. Several diseases can cause the state, with hyperthyroidism – as is in his case – being the most common. Hyperthyroidism occurs when there is high level of free thyroid hormone in the blood circulation from over secretion.

Next, determine if he has any concern regarding the treatment, follow up diagnostic tests or lifestyle medication. Most of the time, these problems can be overcome through gentle discussion and explanation of the procedure and management. Also asked if he has been taking or planning to take alternative approach. If so, the physician can try to know in-depth about the approach and at the same time explaining about current management plan and its advantages and why the physician choose the method on him. Alas, he must know about the complications that may arise if thyrotoxicosis is being untreated.
Most worried complications regarding thyrotoxicosis is cardiovascular involvement. He has a higher chance to get atrial fibrillation and heart failure if it is not controlled. Based on cohort study in those who has hyperthyroidism, older, predominantly male is more likely to develop heart failure.
Other complication is osteopenia, osteoporosis and fractures. Persistent low in thyroid stimulating hormone level (?0.1 mlU/L) can increase new cases of bone-related complications by 2.2 to 4.5 times. Thyroid storm is a life threatening condition often triggered after surgery, trauma, infection or iodine load that can be avoided by initiating adherence to treatment.
In case the causes of non-adherence are ambiguous, four D’s can be used – denial, depression, dependence on alcohol and drug, and dementia. He can be screened for denial and depression which he may be subjected to since it is uncommon to be diagnosed with hyperthyroidism in young male adult. Treatment of these parts can facilitate the treatment process.
Cost is another factor for non-adherence. His job as office boy and low income of the family might prove an obstacle in acquiring the medication. Thus, he may be referred to welfare department to aid in his treatment. Last but not least, outside from his family and friends can be enlisted to improve his adherence to treatment.
Regarding his medication, beta-blocker (propranolol) is used to control symptomatic relief of adrenergic symptoms such as palpitations, tachycardia, heat intolerance. It is usually given to any patient with thyrotoxicosis, resting heart rate ; 90 beats per minute and any symptoms of hyperthyroidism. Since he is being suspected to has dengue, it is kept in hold in view of possible shock and haemorrhage that can be caused by dengue fever.
References
Oxford Handbook of Clinical Medicine
Clinical Notes Medicine © JPBF
Excellence in Clinical Case Presentation in Medicine by Prof Sivalingam et. al.
National Library of Medicine thorugh DynaMed Plus. Ipswich (MA): EBSCO Information Services.

NCBI Library