Case Studies

Case 11: An adult with thyrotoxicosis (Part 13 The endocrine system)

Ms Balcerak, aged 40 years, is a floor supervisor in a department store. She owns a flat on a small development and is involved in local community affairs; she is member of the local Alzheimer's society and photography society. Once every other month she visits her parents, who live in Poland. Approximately 18 months ago she visited her GP complaining of:

• Loss of weight despite increased appetite
• Sweating of face and hands
• Intolerance of heat
• Irritability with colleagues at work

• An anxious, talkative, active person
• Skin moist, hair lank and greasy
• Tachycardia
• Temperature and blood pressure normal
• Fine tremor of hands
• Slight exophthalmos
• Slightly enlarged thyroid gland (goitre)

The GP suspects an over-active thyroid gland and makes arrangements for Ms Balcerak to attend the local medical outpatient department for further investigations. These include blood tests, such as total serum thyroxine, serum thyroid stimulating hormone levels in response to thyroid releasing hormone stimulation, and an electrocardiogram.

The results confirm a diagnosis of thyrotoxicosis with no evidence of heart involvement, and the alternative treatments of antithyroid drug therapy and surgery are discussed with her. Her doctor explains that medical treatment, though prolonged, could be entirely successful but, if unsuccessful, surgery could be contemplated later.

• 1. Why does excessive thyroxine cause an increased rate of oxygen utilization, leading to tachypnoea , tachycardia, weight loss and increased appetite?

• 2. After a partial thyroidectomy, if there is leakage of thyroxine into the bloodstream this can cause an uncontrolled rise in the metabolic rate; what are the signs and symptoms?

• 3. Explain why tetany (a rare complication) may occur and what the signs and symptoms are.

• 4. How might you detect haemorrhagic shock?

Consider this: the patient who has undergone thyroid surgery has failed to adhere to her drug regimen in the postoperative period, informing you she no longer needs this medication now she has had surgery. How might you manage this situation bearing in mind you need to respect the decision the person has made.