Hyperthyroidism Referral Letter

14/05/2024

Dear Dr. Richard Vance,

Thank you for referring Sarah Jenkins. She was seen in clinic today. As you know, Sarah Jenkins is a 34-year-old woman referred for hyperthyroidism.

Past Medical History

• Mild intermittent asthma
• Anxiety disorder

Medications

• salbutamol (Ventolin®) 100 mcg INH PRN
• escitalopram (Cipralex®) 10 mg PO daily
• propranolol 20 mg PO BID

Allergies

• Penicillin (urticaria)

Social History

• Elementary school teacher; lives with husband
• Non-smoker, rare EtOH (1–2 drinks/month)
• Planning pregnancy in the next 1–2 years

Family History

• Mother: hypothyroidism (Hashimoto's thyroiditis)
• Maternal aunt: Graves' disease

History of Presenting Illness

Ms. Jenkins presents with a 3-month history of progressive palpitations, heat intolerance, hyperdefecation, and an unintentional 5 kg weight loss despite an increased appetite. She also notes worsening anxiety and a fine hand tremor. She denies neck pain, dysphagia, or recent viral illness. She reports mild bilateral gritty eye sensations over the last month, without diplopia or vision loss. Initial workup ordered by your office on 02/05/2024 revealed a suppressed TSH of < 0.01 mIU/L, elevated free T4 of 38.2 pmol/L, and elevated free T3 of 14.5 pmol/L. You appropriately initiated propranolol 20 mg PO BID, which has moderately improved her palpitations and tremor.

Physical Examination

Height 165 cm, weight 56 kg, blood pressure 128/76 mmHg. Heart sounds S1 and S2 were normal, with no additional sounds or murmur. The lungs were clear. The thyroid was visible on inspection. On palpation, the thyroid was enlarged. No nodules were palpable. A thyroid bruit was present. There was a tremor with the hands outstretched. The neck was not tender. No head or neck lymphadenopathy. Full EOM. There was a lid lag. There was no scleral injection. There was no proptosis.

Assessment and Plan

Ms. Jenkins is a 34-year-old woman with clinical and biochemical overt hyperthyroidism, almost certainly secondary to Graves' disease given the diffuse goitre, thyroid bruit, positive family history, and mild lid lag. To confirm the etiology and establish baselines prior to therapy, I have ordered TSI (thyroid-stimulating immunoglobulin) levels, a CBC, and a hepatic panel. Given her desire for pregnancy in the next 1 to 2 years, we discussed treatment modalities including antithyroid drugs, radioactive iodine ablation, and thyroidectomy. We elected to initiate medical therapy with thiamazole (methimazole, Tapazole®) 15 mg PO daily, with a plan to transition to propylthiouracil prior to conception if she remains on medical therapy at that time. I have counselled her extensively on the rare risks of agranulocytosis and hepatotoxicity, advising her to discontinue thiamazole and seek urgent medical attention for a CBC if she develops fever, sore throat, or jaundice. She will continue propranolol 20 mg PO BID for symptomatic relief of her adrenergic symptoms until euthyroid, and her asthma remains stable with no bronchospasm on this low dose. For her mild ocular grittiness, I recommended preservative-free artificial tears PRN and strict smoking-avoidance. Her underlying anxiety disorder is likely exacerbated by thyrotoxicosis, so she will maintain her current dose of escitalopram 10 mg PO daily. She will repeat TSH, free T4, and free T3 in 4 weeks, and I have scheduled a follow-up appointment in 6 weeks to review her clinical response and titrate therapy accordingly.

Thank you for involving me in her care.

Sincerely,

Dr. Elena Rostova, MD, FRCPC Internal Medicine Specialist