A 46-year-old woman presents to her GP as she has been feeling unwell over the last few months and things appear to be getting worse.


Presenting complaint

“I’ve just not been feeling right doctor, I feel terrible in fact. I’m losing weight, my bowels have taken a turn for the worse and I’m struggling to sleep. I’m really worried, my heart is racing sometimes, I think something is seriously wrong.”

Clarify the details surrounding the symptoms mentioned in the presenting complaint

Weight loss:

  • How much?
  • Duration?
  • Appetite?
  • Diet?
  • Change in level of exercise?


Bowel habit (Clarify what exactly the issue with the bowels is)

  • Diarrhoea vs constipation?
  • Frequency of bowels opening?
  • Any blood in the stool?
  • Any change in colour of the stool? (malaena / steatorrhoea)
  • When did the bowel habit change?
  • Are there any obvious triggers? Change in diet?
  • What is her normal bowel habit?
  • Any abdominal pain?



    • How many hours a night on average do you sleep?
    • Do you have any ideas as to what’s causing your sleeping problems?


Heart racing (palpitations)

      • How often does this occur? / When did it start?
      • Does it occur at rest, or only during exertion?
      • Any obvious triggers?
      • Do the palpitations feel regular or irregular?
      • Any associated chest pain or shortness of breath?
      • Any presyncope or syncope?

Ask about any other symptoms that haven’t been mentioned and check for any pre-existing medical problems or regular medication.

Patient’s response…

“I’ve lost about 8kg over the last 6 months. My appetite has been fine, I’ve been eating more if anything! I go to the gym twice and week and have done for many years, so no change there.”

“Sorry doctor, I should have been more specific, it’s just embarrassing.  I’ve got diarrhoea, I’m going about 3-4 times a day, normally I’d just go once in the morning. The diarrhoea started about 4 months ago and hasn’t really improved since. There’s been no change in the colour and no blood in the stool. I haven’t managed to identify any obvious trigger, it’s just always happening, regardless of what I eat or do. I don’t have any abdominal pain or bloating.”

“The heart racing really scares me, I keep worrying I’m having a heart attack. It seems to come on suddenly at random intervals, I can’t identify any triggers. I don’t get any chest pain or shortness of breath, but I sometimes feels a bit dizzy. I haven’t ever lost consciousness though. It’s hard to say if it’s regular, I’m pretty sure it’s irregular to be honest, but I couldn’t be totally sure.”

“Sorry I forgot to mention that I’ve also been feeling a bit shaky, my hands at times really tremble, despite me not being particularly anxious, it’s really weird. Otherwise I’m fairly fit and well, I don’t have any other medical problems and don’t take any regular medication other than the oral contraceptive pill.”


Cardiovascular examination

Abdominal examination

Thyroid status examination


On examination

      • Her hands are warm and sweaty
      • She has an irregularly irregular pulse of 110 bpm
      • Auscultation reveals normal heart sounds with no added sounds
      • She has a significant resting tremor
      • There is some mild exophthalmos
      • She has a visible diffuse goitre which is palpable
      • On auscultation there is a bruit over the goitre
      • She has hyperreflexia
      • Abdominal examination is unremarkable


Full blood count – unremarkable

Urea & electrolytes – unremarkable

T3 & T4significantly raised


Thyroid- stimulating hormone receptor antibodiespositive



Atrial fibrillation



Graves’ disease

Graves’ disease is the most common cause of hyperthyroidism.

It’s an autoimmune disease directed against thyroid stimulating hormone receptors.

The autoantibodies stimulate the TSH receptors causing ↑ T3 & T4 production.

It is most common in middle aged women, with a female to male ratio of 8:1.

Patients become symptomatic due to thyrotoxicosis (high levels of T3 & T4).


Other causes

Toxic multinodular goitre

Toxic thyroid adenoma


Drug induced 


A common initial management is known as “block and replace” in which Carbimazole is used to inhibit the production of thyroid hormones and levothyroxine is then titrated alongside monthly TFTs to give the patient appropriate levels of circulating thyroxine.   After 12-24 months the Carbimazole is stopped and the patient’s TFTs are monitored. Approximately 50% will relapse and become hyperthyroid again, which indicates the need for definitive therapy.

      • Radioiodine – most patients become hypothyroid after treatment and require replacement
      • Total thyroidectomy


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