Problem 49 A woman with palpitations

She describes a 10 kg weight loss over 2 months, heat intolerance, excess sweating, anxiety, sleep disturbance (although she has attributed this to her knee pain), infrequent but mild palpitations and tremulousness. She denied any change in appetite, has had no diarrhoea and no ocular symptoms.

Physical examination reveals a slim lady of 59 kg, height 164 cm. She has warm sweaty palms. There is no palmar erythema. She has a goitre with the thyroid approximately 5× its normal size. It is irregular and nodular. She has thyroid stare due to lid retraction and lid lag but no exophthalmos. She has atrial fibrillation.

An ECG (Figure 49.1) shows atrial fibrillation.

Figure 49.1

Laboratory investigations include the following:

Investigation 49.1 Summary of results

A thyroid technetium scan (Figure 49.2) shows an enlarged thyroid with generally increased tracer uptake in a patchy distribution consistent with a multinodular goitre.

Figure 49.2

The patient is treated with carbimazole 20 mg bd and propranolol 20 mg bd. Warfarin is started and titrated to an INR of 2–2.5. She is seen with thyroid function tests initially at 3-weekly intervals to check that the thyroid hormone levels are falling and to allow reduction of the carbimazole dose.

After 3 weeks, she reports the resolution of most of her symptoms, particularly reduced anxiety. Her heart rate is 60 and irregularly irregular consistent with atrial fibrillation. Blood tests are as follows:

Investigation 49.2 Summary of results

The dose of carbimazole was reduced to 15 mg bd and 3 weeks later to 15 mg daily.

Six weeks later her free T4, free T3 and TSH are all normal although she remains in atrial fibrillation.

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