HYPERTHYRODISM

Overview:

Thyroid gland disease is one of the most common ductless gland disorders.
Hyperthyroidism is a disease, which results from excessive secretion of thyroid
hormone by the thyroid gland in the body (Cooper & Biondi, 2012). Women
population is more susceptible to thyroid diseases than men. (Cabrera & Schub,
2012). According to National Prescribing Centre (2002) thyroid disease mostly
occurs at the ages between 30 to 50 years. In UK overt hyperthyroidism is seen
in the 2% of the women population and 0.2% of the men population. Most
common cause for the hyperthyroidism is Grave’s disease, which accounts for
about 60-80% of the hyperthyroidism cases (Weetman, 2010). The second most
common reason for hyperthyroidism in UK is toxic multinodular goitre. Toxic
thyroid nodule is the other common reason for hyperthyroidism and it accounts
for around 5% of total hyperthyroidism cases. (Franklyn & Boelaert, 2012).

Introduction:

This case study will explore and evaluate the different steps to identify and treat
a patient with hyperthyroidism. These steps includes collecting history of the
patient, physical assessment, differential diagnosis, diagnosis, investigations and
devising treatment plan for the patient. After reading this case study reader will
be supplied with a brief understanding about this particular disease condition.

This case study is based on a female patient who is 48 years old who comes to
the hospital with a complaint of swollen neck and irritation in her eyes. She is

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also concerned that she has lost her weight a lot recently. Her hands were
trembling and she complained that she was feeling very tired. According to
Nursing and Midwifery Council’s rules and regulations, it is very important to
maintain confidentiality of every patient who is coming to the hospital (Nmc-
uk.org, 2008). Patient’s name is changed to Kate to maintain confidentiality.

History Collection:

To provide practitioner with a clear picture of the disease or problem a clear and
thorough history collection is necessary (Viljoen, 2009). It is always advisable to
introduce yourself to the patient before you start with history collection (Bickley &
Szilagyi, 2008). According to Cox (2012) it is very important to make the patient feel
ease and comfortable and it is advisable to call the patient with his/her name. This will
help to build a bond with patient and also this will boost the confidence of patient.
This makes patients to communicate freely and effectively which helps to effective
data collection. The initial step in history taking is collecting the demographic data of
the patient. Kate is a 48-year-old lady who is currently working in a private firm. She
is married and is mother of two children. She is living with her husband and children.
She had no history of any significant medical or surgical illness. She stated that she is
not allergic to any food or drugs. She also stated that she does not possess any
unhealthy habits of smoking or alcoholism. Family history plays an important role in
history collection (Jarvis, 2009). While enquiring about the family history of Kate,
she stated that her father was a hyperthyroid patient. There are chances that
hyperthyroidism can be inherited from the family members (Talley & O'Connor,
2010).

She also stated that there is no other significant history of illness in her family.
Regarding her menstrual history she said that she had irregular menstrual
cycles. Irregular menstruation can be seen in patients with hyperthyroidism
(Mosby's expert 10-minute physical examinations, 2005). On asking about the

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main concerns or difficulties she is facing now she said that she weighed 48 Kg
previously and she lost 8 kg recently and she is 40 kg now despite the fact that
she is having an increased appetite. According to Cox (2010) weight loss
accompanied by increased appetite indicates chances of hyperthyroidism. She
also felt that her neck is swelled. Swelling of the neck can be associated with the
enlargement of thyroid gland. (Chiasera, 2013).

She also complained that she is intolerant to heat and sweats excessively.
According to Cooper (2003) intolerance to heat and excessive sweating points
towards hyperthyroidism. She also said that her hands were trembling and she
was feeling less active than what she was before and she feels nervous and tired.
Talley & O’Connor (2010) describes that anxiety, trembling, nervousness,
inactiveness can be related to hyperthyroidism. Kate said that she is suffering
from sleeplessness and irritation in eyes with burning sensation.

Physical Examination:

Systematic physical assessment of patients has become an integral part of

nursing assessment as nurses have expanded their roles into advanced
practicing (Doyle et al, 2013) Physical examination, which is well defined and
precise, is very important step in diagnosis of disease. Patient’s privacy is the
most important thing to consider while conducting the physical examination.
Patient should be explained about the procedures and should get a consent from
the patient before physical examination. To start with the physical examination,
the vital signs of the patients needed to be checked. Body temperature of Kate
was checked it showed a reading of 38 degree Celsius. Pulse was checked and it
showed 110 beats per minute and respiration clocked at 28 breath per minute.
Blood pressure showed a reading of 130/80 mm of hg. Increases in the pulse
rate can be associated with hypothyroidism (Lowrance, 2012). The signs and
symptoms of the patient indicates that she is having thyroid-related disorders, so

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it suggested that she should undergo a formal assessment of the endocrine
should be conducted.

Among the endocrine glands in the body thyroid is regarded as the largest gland.
Enlargement of thyroid glands, which commonly caused by deficiency of iodine
in the body, is detected more in women. Thyroid gland is shaped like a butterfly
and is situated at lower part of neck underneath larynx covering the trachea
(Weeks, 2005). While examining the thyroid gland checking for any enlargement
of the gland is necessary. Thyroid gland will be visible under the cricoid cartilage
when it is normal in size. In case of phenomenon of enlargement of thyroid,
which is termed as goitre, thyroid can be seen when the patient extends her
neck. Enlargement of thyroid can be visible as the neck of the patient will be
bulged outward (Monaco et al, 1993).

The best way to examine the shape of thyroid gland is to ask the patient to
swallow some liquid and observing the movements of the gland (Macleod, 2009).
I gave Kate a glass of water and asked her to drink it. While she was swallowing
the glass of water I watched the movement of the thyroid gland. While she
swallowed the glass of water I observed that her bulge in the neck was moving
upwards, which suggests presence of goitre (Macleod, 2009). We also have to
check for any or dilated veins in the neck and I was not able to find any of these
in Kate’s case.

For the palpation of the thyroid gland I first used posterior approach by making
the patient seated and I stood behind the patient and tried to locate the thyroid
by palpating around cricoid cartilage and suprasternal notch. On palpation the
examiner should check for softness, texture, size, mobility, tenderness,
consistency and shape of the gland (Hui, 2011). Size of the gland is checked to
know whether there is any enlargement of thyroid. Nodularity of the gland is
checked to identify the type of goitre. Normally thyroid glands are soft, if it feels
like nodular then we can associate it with multinodular goitre, it is firm then it
could be simple goitre. The case of chronic lymphocytic thyroiditis can be

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identified by a hard gland and Riedel's struma is characterized by a stony-hard
nodule. In the case of Kate her thyroid was rubbery, firm and bulged which
points towards hyperthyroidism. Palpating while patient is swallowing gives
thrill or palpable murmur can be felt then it indicates thyrotoxicosis. Examiner
has to check for any bulging in the cervical lymph nodes, as this can be an
indication of thyroid cancer.

After posterior palpation it time now for to do the anterior palpation in which
the patient is asked to sit or stand and the examiner palpates from cricoid
cartilage to suprasternal notch. Trachea’s position is also observed as this might
have changed its location because of retrosternal gland.

Percussion is rarely used in physical examination of goitre. It is used in the case

when there will be extension of goitres below the sternum and this goitre is
called retrosternal goitre. It can be detected if percussing of sternum produces
dull sound (Leach, 2010). To perform the auscultation stethoscope needs to
placed over the bulging part of the neck and listen for bruit. If you hear a bruit
then the lesion can be associated with increase in blood supply. If you hear bruit
over thyroid gland then it can be associated with hyperthyroidism (Leach, 2010).

The patient was asked to perform the Pemberton’s manoeuvre to check for the
Pemberton’s sign. (Jukic & Kusic ,2010) Patient was asked to raise her both
hands simultaneously until it touches the sides of the face. Ask the patient to
continue in the same posture for few moments and examiner should check the
patient’s face to find any congestion (plethora) and cyanosis. Patient’s neck veins
needed to be observed for any signs of enlargement or distension (Wallace &
Siminoski, 1996). To identify whether there is any obstruction in the thoracic
inlet due to retrosternal mass or retrosternal goitre a test should be conducted.
In this test the patient is asked to breath deeply through the mouth and carefully
listen for any stridor (Talley & O'Connor, 2010).

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Physiologic tremor is a phenomenon, which occurs to all normal individual and
can be seen in an increased form due to hyperthyroidism, physical tiredness or
anxiety. As it is hard to see with naked eye, a test is conducted by extending the
arms of the patient and keeping a small paper on top of the hand and increased
tremor is detected for hyperthyroid patient (Campbell, 2012). Examination of
nails helps to find any signs of hypothyroidism. Examine the nails for the brown
discolouration and this condition is known as Plummer’s nail or onycholysis.
Pretibial myxoedema or Graves dermopathy is also checked which can be
identified by an orange peel appearance of skin which is mostly seen on the
lower leg’s anterior aspects and spreading to dorsum of the feet (Rapoport &
McLachlan, 2000). Kate was identified with this orange peel appearance. Thyroid
acropathy is a manifestation of thyroid disease, which can identified by digital
clubbing, which was found in the case of this patient (Lewis et al, 2013).
On further assessment the patient was detected with premature greying of hair
and her hair was thin and brittle in nature and she was detected with alopecia.
(Heymann, 2010). On physical examination of eye Kate was identified with other
hyper thyroidal indications like periorbital puffiness, conjuctival edema and
exophthalmoses. Patient was examined for Grave's opthalmopathy which can be
identified by retraction of upper eyelid, inflammation of orbit around the eye,
edema, erythema or redness, conjunctivitis and proptosis or bulging of the eye
(Moore (2007).)

The skin of the patient affected with hyperthyroidism will be often warm, moist
and silky smooth. To check proximal muscle weakness, ask the patient to squat
down and see if she can get up easily. Muscle weakness of hyperthyroidism is
usually most noticeable in the proximal muscles.

After the completion of physical assessment, we got a number of differential

diagnosis for Kate and they are hyperthyroidism due to Grave’s disease,
thyroiditis, thyroid carcinoma, toxic nodular goitre and hypothyroidism. In case
of carcinoma of thyroid there is a hard and stony thyroid gland and is tethered
to the larynx on swallowing, which can cause breathlessness (Talley & O'Connor,
2010). These symptoms were not seen in the case of this patient. So the patient

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can be ruled out of the chances of being affected by carcinoma of thyroid.
Hypothyroidism is indicated by increased sensitivity to cold, slow heart rate,
unexplained weight gain (Lough, 2013). Kate doesn’t show any of these
symptoms so we can exclude hypothyroidism from the list. In toxic nodular
goitre there will be dyspnoea, dysphagia and neck pressure with the signs and
symptoms of hyperthyroidism (Mitchell et al, 2011). Thyroiditis is characterised
by the inflammation of the thyroid gland and will have the symptoms as same as
hypothyroidism. So thyroiditis can be excluded from the series of differential
diagnosis. At last, for confirming diagnosis of hyperthyroidism, some lab
investigations need to be carried out. After completion of history taking and
physical assessment procedures, signs and symptoms points towards
hyperthyroidism related to Grave’s disease.

INVESTIGATIONS

The main tool for the confirmation of any diagnosis is laboratory investigations.
The first and foremost biochemical investigation for the diagnosis of
hyperthyroidism is thyroid function test. This test is carried out to know about
T4(serum thyroxine), TSH(thyroid stimulating hormone), and T3 (tri-
iodothyronine) levels (Heymann, 2010). The normal value of TSH is 0.2 -
5.5mu/l , normal value of T3 is 3.5-6.5pmol/l, and T4 is 10.3-19.4pmol/l (Cox,
pp309, 2004). In hyperthyroidism, TSH value will be low and at the same time
T3 and T4 level will be high (Muchnick, 2007).

Another blood test for the diagnosis of hyperthyroidism is checking the serum
calcium level and the value of serum calcium will be at increased level in those
who have hyperthyroidism (Faqi, 2013). Radioactive iodine uptake test, also
known as thyroid scan, helps to identify the reasons for dysfunction of thyroid.
Normally, iodine is used by the thyroid gland to produce thyroxine and the
excess amount of iodine excreted in urine.

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Checking the amount of iodine absorbed by the gland can identify the reason for
any particular thyroid disease. This scan can be conducted after 24 hours of
administering premeditated dose of radioactive iodine intravenously or by oral
route. If the radioactive iodine is more than 35%, it indicates the increased
amount of thyroxine production by the thyroid gland, which is an indication of
Grave’s disease (Feldman & Nelson, 2004).

MRI or Orbital CT scan is conducted to identify any ocular involvement especially

exophthalmoses. The blood test conducted on the patient resulted in lower TSH
level and elevated T3 and T4 level. The radioactive iodine uptake scan showed an
increased uptake of radioactive iodine that is more than 35%, which confirms
Grave’s disease. The findings from the history collection, physical assessment
and the laboratory values points towards hyperthyroidism resulted from Grave’s
disease. Early identification and timely treatment of Grave’s disease is very
important as it can be life threatening if it remained untreated.

Treatment
The goal of treatment for hyperthyroidism is to control the overproduction of
thyroid hormones and to maintain normal thyroid level. The treatment regimens
available are radioactive iodine therapy, anti-thyroid drug therapy and surgery.

Propylthiouracil, thiamazole and carbimazole are the three main drugs that are
used as anti-thyroid drugs (thionamides) used in treating hyperthyroidism.
(Scanlon & Rees, 2008). Carbimazole is the most common thionamide used in UK
for the treatment of hyperthyroidism and propylthiouracil is used as second line
(Joint Formulary Committee, 2014) An initial dose of 15-40 mg of carbimazole is
given daily for 4-8 weeks until the normal thyroid levels are achieved. A gradual
reduction of dose is undertaken and maintained at dose of 5-15 mg daily. The
treatment period required is 12 to 18 months. An initial daily dose of 200-400

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mg of propylthiouracil is given which is gradually reduced to a daily dose of 50-
150 mg (Terris & Gourin, 2011).

Radioactive iodine (RAI) therapy is a treatment used for the ablation of thyroid
gland and is a common treatment for hyperthyroidism. (Lewis et al, 2013). Any
long-term risks of this therapy is not associated, but it is not normally
administered for pregnant or breast-feeding women and for very young patients.
This therapy aims to administer enough radiation to reduce the thyroid to
normal levels without making the patient hypothyroid. This is mostly achieved
by two to three months of treatment.

If the patient is intolerable to thionamides or refuses RAI, then the next clinical
option is removal of thyroid gland fully (thryroidectomy) or partial removal
(subtotal thyroidectomy) (Habermann, 2006). Patients with very large goitres
or with nodules, which are suspicious; and pregnant and very young patients, are
not advised to undergo subtotal thyroidectomy. To reduce the heart rate and
other complications of hyperthyroidism beta-blockers such as propranolol is
used. This treatment is used as a supportive therapy and used in the
preoperative period of thyroidectomy.

Conclusion:
In this case study we used the case scenario of a patient with hyperthyroidism to
explore and evaluate a common disease, which affects a good number of people.
The study outlines the different aspects of the disease and carefully evaluated
the three distinct ways of treating this disease. Timely diagnosis and selection of
right treatment method play an important role in treating this disease, which can
be life-threatening if left untreated. This case study helped me to know more
about thyroid related diseases and enhance my knowledge about diagnosing,
treating and caring of patients affected by thyroid diseases. The preparation I did

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by reading books, journals, articles and online materials improved my
information collecting and evaluation skills.

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