Comprehensive Hyperthyroid Disease Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: Jessica Lynn Walker
Date of Birth: 04/15/1980
Age: 44
Gender: Female
Medical Record Number: 20250307
Date of Admission: 03/07/2025
Primary Care Provider: Dr. Laura Green

Chief Complaint (CC)

"I’ve been feeling really anxious and shaky lately, and I’ve noticed I’ve lost a lot of weight even though I’m eating normally."

History of Present Illness (HPI)

Jessica Walker is a 44-year-old female presenting with complaints of increased anxiety, restlessness, and unintended weight loss of 10 pounds over the past month. She reports feeling shaky, has had difficulty sleeping, and experiences frequent hot flashes. She also mentions a noticeable swelling in her neck, which she attributes to her thyroid. The patient reports feeling more fatigued than usual but continues to experience an increased appetite. She has also noticed a slight tremor in her hands. There is no history of palpitations or chest pain, but she feels short of breath when walking up stairs.

She denies any recent infections or changes in her diet.

Past Medical History (PMH)

  • Hyperthyroidism – diagnosed 3 years ago, previously treated with antithyroid medication (Methimazole)
  • Anxiety Disorder – diagnosed 5 years ago, managed with cognitive behavioral therapy
  • Gastroesophageal Reflux Disease (GERD) – diagnosed 10 years ago, managed with omeprazole

Surgeries & Procedures

  • Thyroidectomy (partial) 2 years ago due to multinodular goiter

Allergies

  • Penicillin – rash

Medications

  • Methimazole 5 mg daily
  • Omeprazole 20 mg daily
  • Vitamin D 1000 IU daily

Family History (FH)

  • Father: Alive, 65, with hypertension and hypothyroidism
  • Mother: Alive, 63, with hyperthyroidism (Graves’ disease)
  • Brother: Alive, 42, healthy

Social History (SH)

  • Smoking: Never smoked
  • Alcohol: Drinks socially (1-2 drinks per week)
  • Drug Use: Denies illicit drug use
  • Occupation: School teacher
  • Living Situation: Lives with her spouse and two children

Review of Systems (ROS)

  • General: Weight loss, increased appetite, fatigue
  • Cardiovascular: No chest pain, occasional palpitations
  • Respiratory: Shortness of breath with exertion, no cough
  • Gastrointestinal: No nausea, normal bowel movements
  • Endocrine: Heat intolerance, tremors, increased sweating
  • Neurological: Anxiety, restlessness, no focal neurological deficits

Physical Assessment Findings

Vital Signs:

  • Temperature: 99.4°F (37.4°C)
  • Heart Rate: 110 bpm, regular
  • Respiratory Rate: 18 breaths/min
  • Blood Pressure: 128/84 mmHg
  • Oxygen Saturation: 97% on room air
  • Height: 5'7"
  • Weight: 137 lbs.

General Appearance: Alert, anxious, and slightly diaphoretic
Cardiovascular: Tachycardia, no murmurs, pulses palpable
Respiratory: Clear breath sounds bilaterally
Neck: Mild diffuse swelling in the anterior neck, consistent with goiter
Skin: Warm to touch, moist, slight tremor in hands
Neurological: Hyperreflexia, no focal deficits

Laboratory Results

Thyroid Function Tests

Test Result Reference Range
Free T4 3.4 ng/dL 0.8-2.0 ng/dL (elevated)
Free T3 7.5 pg/mL 2.3-4.2 pg/mL (elevated)
Thyroid Stimulating Hormone (TSH) 0.02 µIU/mL 0.4-4.0 µIU/mL (low, indicates hyperthyroidism)
Thyroid Peroxidase Antibodies (TPO) 35 IU/mL <35 IU/mL (normal)

Complete Blood Count (CBC)

Test Result Reference Range
White Blood Cell Count (WBC) 5.6 x10³/µL 4.0-11.0 x10³/µL
Hemoglobin (Hgb) 14.2 g/dL 12.0-16.0 g/dL
Hematocrit (Hct) 42% 36-46%
Platelets (Plt) 200 x10³/µL 150-450 x10³/µL

Basic Metabolic Panel (BMP)

Test Result Reference Range
Sodium (Na) 138 mEq/L 135-145 mEq/L
Potassium (K) 4.2 mEq/L 3.5-5.1 mEq/L
Chloride (Cl) 100 mEq/L 98-107 mEq/L
Bicarbonate (HCO₃) 22 mEq/L 22-28 mEq/L
Blood Urea Nitrogen (BUN) 15 mg/dL 7-20 mg/dL
Creatinine (Cr) 0.9 mg/dL 0.6-1.2 mg/dL
Glucose (fasting) 102 mg/dL 70-99 mg/dL

Liver Function Tests (LFTs)

Test Result Reference Range
Alanine Aminotransferase (ALT) 18 U/L 10-40 U/L
Aspartate Aminotransferase (AST) 20 U/L 10-40 U/L
Alkaline Phosphatase (ALP) 90 U/L 45-115 U/L
Bilirubin, Total 0.4 mg/dL 0.1-1.2 mg/dL

Electrocardiogram (ECG)

Findings: Sinus tachycardia, normal QT interval, no arrhythmias

Imaging and Diagnostics

Neck Ultrasound

Findings:

  • Bilateral enlarged thyroid glands, consistent with diffuse goiter
  • No evidence of thyroid nodules or malignancy