Clinical Case: Loose Bowel Movement

JS, 29 y/o female, single, from Cavite came in for Loose Bowel Movement.

History of the present illness:

5 months PTA, the patient noted tremors with associated palpitations and heat intolerance. There was
no consult done and no medications taken.

1-week PTA, the patient still had above signs and symptoms and now noted loose bowel movement about
4x/day, stool was characterized as watery, non-blood streaked, non-foul smelling but with no associated
febrile episodes or abdominal pain. She would complain of bowel movements every time she would eat. At
this point, no consults were done and no medications was taken except for taking some Gatorade.

On the day of admission, persistence of symptoms prompted consult in a local clinic where she was noted
to have anterior neck mass with protrusion of her eyeballs. She was also noted to be tachycardic with
irregular rhythm hence was then referred to the emergency room and was subsequently admitted.

Past Medical History

No known co-morbidities

Family Medical History

No DM/HPN/cancer, No history of thyroid problems,

Personal-Social History
Non-smoker, non-alcoholic beverage drinker
A college graduate and works as an office clerk

OB-Gyne History
Go, with irregular menses occurring every 2-3 months, LMP: Aug 2019

Physical examination
Awake, alert, coherent, not in respiratory distress
BP: 90/60mmHg HR:142 bpm RR: 18 bpm O2 Sats: 97% at room air T 37.3 C
ENT : Anicteric sclerae, pinkish conjunctivae, (-) cervical lymphadenopathy, (-) naso-aural discharge, (+)
diffusely enlarged non-tender anterior neck mass with bruit on the lateral aspects of the mass, moves with
deglutition, (-) palpable nodularities, (+) exophthalmos, with lid lag and scleral show
CHEST : Equal chest expansion, Clear breath sounds
CVS : Adynamic precordium, distinct heart sounds, tachycardic, irregular rhythm, (-) murmurs
ABDOMEN : Flat, hyperactive bowel sounds, soft abdomen, (-) masses/ tenderness
EXT : Bounding pulses, moist skin, warm, extremities, No edema, DTRs +++, muscle strength 5/5 on all
extremities, (+) fine tremors on the fingers upon extension of upper extremities,

Guide Questions:
1. What is your diagnosis/impression for the case?
Diffused toxic goiter to consider Graves’ disease in thyroid storm with congestive heart
failure(?) and ophthalmopathy
 Make an audit of the significant points in the history that point towards your diagnosis.
 History
o (+)
 Tremor
 Palpitations
 Heat intolerance
 Loose bowel movement
 Watery, non-blood streaked, non-foul smelling
 Bowel movements every time she would eat
 Irregular menses occurring every 2-3 months, LMP: Aug 2019
o (-)
  Loose bowel movement, no associated febrile episodes or abdominal pain
 No history of thyroid problems
 Non-smoker, non-alcoholic beverage drinker
 Physical Examination
o (+)
 Anterior neck mass, diffusely enlarged non-tender anterior neck mass with bruit
on the lateral aspects of the mass, moves with deglutition
 Protrusion of her eyeballs, exophthalmos, with lid lag and scleral show
 Tachycardic, HR:142 bpm
 Irregular rhythm of heart sounds
 Hyperactive bowel sounds
 Fine tremors on the fingers upon extension of upper extremities
 DTRs +++
o (-)
 BP: 90/60mmHg, RR: 18 bpm, O2 Sats: 97% at room air
 T: 37.3 C
 Cervical lymphadenopathy, palpable nodularities
 Distinct heart sounds, no murmurs
 Abdominal masses/ tenderness
 muscle strength 5/5 on all extremities

Not part of guide questions but additional questions to ask in Hx:

Other S/Sx in thyrotoxicosis:
Hyperactivity, irritability, dysphoria
Fatigue and weakness
Weight loss with increased appetite (sometimes though there is weight gain bc of increased food intake)
Polyuria
Loss of libido
Insomnia

Addt’l PE for thyrotoxicosis:

Muscle weakness, proximal myopathy
Palmar erythema, onycholysis, and, less commonly, pruritus, urticaria, and diffuse hyperpigmentation
Diffuse alopecia

Labs for thyrotoxicosis:

osteopenia
mild hypercalcemia
hypercalciuria

 Discuss relevant pathophysiologic processes applicable in this case to explain the patient’s
signs and symptoms.

Signs and symptoms Pathophysio

Tachycardia w/ Irregular Overstimulation of the sympathetic nervous system and decreased

Rhythm vagal modulation

Tremors, Palpitations

Increased energy production of cells in the body/increase in the cells’

basal metabolic rate
Hyperreflexia (DTRs +++)
Heat intolerance Increased metabolic rate

LBM in Gastrointestinal transit time is decreased, leading to increased stool

thyrotoxicosis/Hyperactive frequency, often with diarrhea and occasionally mild steatorrhea.
bowel sounds

Hyperthyroidism in Graves’ Caused by thyroid stimulating immunoglobulin (TSI), Thyroid

disease: peroxidase (TPO) and thyroglobulin (Tg) antibodies occur in up to 80%
of cases. Because the coexisting thyroiditis can also affect thyroid
function, there is no direct correlation between the level of TSI and
thyroid hormone levels in Graves’ disease.

Ophthalmopathy: There is infiltration of the extraocular muscles by activated T cells; the

release of cytokines such as interferon γ (IFN-γ), tumor necrosis factor
(TNF), and interleukin-1 (IL-1) results in fibroblast activation and
increased synthesis of glycosaminoglycans that trap water, thereby
leading to characteristic muscle swelling.
Increased fat is an additional cause of retrobulbar tissue expansion.
The increase in intraorbital pressure can lead to proptosis, diplopia,
and optic neuropathy.

2. What are your differential diagnoses? Give your basis for each.
 Burch-Wartofsky score:5+0+10+25+0+0 = 40

Differential Rule In Rule Out

Thyroid Storm (+) thyrotoxicosis signs and symptoms
(+) cardiac manifestations (severe presentation
of thyrotoxicosis)

Sscored ~40 in the Burch-Wartofsky Diagnostic

Criteria.
(See figure 1)

Possibly triggered by infection

Thyrotoxicosis +) Heat intolerance
 Graves’ Disease (+) Palpitations
 Thyro-toxicosis factitia (+) Diarrhea
(+) Tachycardia
 Pituitary Adenoma- (+) Tremor
induced thyro- (+) Goiter
toxicosis (+) Oligomenorrhea
(+) Lid lag, scleral show

(+) warm, moist skin

(+) fine tremors on the fingers upon extension of
upper extremities

Graves’ disease:
(+) diffusely enlarged non-tender anterior neck
mass with bruit on the lateral aspects of the
mass, moves with deglutition,
(-) palpable nodularities,
(+) exophthalmos, with lid lag and scleral show

Features of Graves’ disease.

A. Ophthalmopathy in Graves’
disease; lid retraction, periorbital edema,
conjunctival injection, and proptosis are
marked.
B. Thyroid dermopathy over the lateral aspects of
the shins. (in <5% of graves patients; those with
moderate->severe ophthalmopathy)
C. Thyroid acropachy or clubbing (in <1%)
Hashimoto’s Disease (+) thyrotoxicosis signs and symptoms (transient Eventual symptoms of
hyperthyroidism) hypothyroidism after transient
(+) diffusely enlarged, symmetric hyperthyroidism such as
(-) intolerance to cold
(-) dry skin
(-) weight gain

Multinodular Toxic Goiter (+) ophthalmopathy

(+) thyrotoxicosis signs and symptoms (-) nodular

Drug-induced Thyrotoxicosis (+) Thyrotoxicosis signs (+) exophthalmos

(+) goiter
Thyrotoxicosis Factitia (-) history of exogenous thyroid
source use (LT4, “supplements”,
“herbal”, lithium)

Subacute Thyroiditis (+) hyperthyroidism (-) neck pain/tenderness

(+) anterior neck mass (-) neck fever
(-) viral infection history
Thyroid Hormone Resistance (+) hyperthyroidism (+) ophthalmopathy
Syndrome (-) family history of disease

Toxic Adenoma (+) hyperthyroidism (-)nodules

(+) anterior neck mass

TH-secreting Pituitary (+) hyperthyroidism (-) mass effect symptoms

Adenoma (+) goiter (headache, blurring of vision)
(+) ophthalmopathy

Congestive Heart Failure (+) Tachycardia (+) adynamic precordium

(+) irregular rhythm (+) distinct heart sounds
(-) murmurs

Pheochromocytoma (+) Tachycardia (-) Hypertension uncontrolled by

(+) Tremors medication
(+) Heat intolerance (-) Heavy sweating
(+) diarrhea (-) headaches
(-) nausea
(-) goiter

Autonomic Nervous System (+) fine tremors (-) Dizziness from orthostatic
Dysfunction (+) ptosis hypotension
(dysautonomia) (+) diarrhea (-) Heavy sweating
(-) Incontinence
(-) Blurring of vision
(-) sexual problems
(-) goiter

Functional Thyroid CA (+) ant neck mass (-) lymphadenopathy

(+) diffused, enlarged mass (+) mass moves with deglutition

Struma Ovarii (+) hyperthyroidism (-) abdominal pain

(-) palpable lower abdominal mass
(-) abnormal vaginal bleeding
(+) goiter

Acute gastroenteritis diarrhea (-) abdominal pain, vomiting

3. How will you work-up the patient to be able to obtain the correct diagnosis?

Lab Test Rationale

TSH/FT4 Confirm diagnosis thyrotoxicosis
CBC Evaluate presence of infection
TRAb Rule in/out Graves Disease. TRAb
Chest X-ray To confirm congestive heart failure
Serum Electrolytes Assess electrolytes in the setting of diarrhea
ECG and 2D Echo Assess cardiac function
Thyroid Scan r/o hashimotos, multinodular toxic
goiter,adenoma, etc.
Liver function test (ALT and AST) Assess liver function for medications
Kidney function test (BUN & Creatinine) Assess kidney function for medications

 What laboratory tests will you request?

 Present a diagnostic algorithm whenever possible.
 4. How will you approach the management of this patient?
 What are your treatment goals?
 Make a short list of the available treatment options/modalities.
 Give your general management for this patient.
Management goals
1. Decreasing the symptoms of hyperthyroidism induced by B-adrenergic tone
2. Decreasing thyroid hormone synthesis
Treatment options
1. Administration of thionamides (e.g. propylthiouracil, thiamazole, carbimazole)
2. Beta blockers
3. Radioiodine ablation
4. Surgical intervention
General management plan
Prescribe thioamides methimazole/ carbimazole (not proply because it is hepatotoxic
Prescribe propranolol to control B1 adrenergic
Assess thionamide effectivity if not effective do Radioiodine ablation
- Make sure patient will not be pregnant
Surgery if patient prefers this over radioiodine
Ophthalmopathy requires no active treatment when it is mild or moderate because there is
spontaneous improvement

When Graves’ eye disease is active and severe, referral to an ophthalmologist is indicated and objective
measurements are needed, such as lid-fissure width; corneal staining with fluorescein; and evaluation of
extraocular muscle function (e.g., Hess chart), intraocular pressure and visual fields, acuity, and color
vision.

The preceptor will give you the laboratory test results after answering Question #3.