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-A 38-year old female

-swelling of her anterior part of the neck

excessive

-hand sweating of three-month duration

-lately became less

tolerant of hot weather.

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problem

-A 38-year old female -middle age,prone to middle age problem/hormonal woman problem - immunocompetent -middle age problem + female such as (cancer ,thyroid, pregnancy)

-swelling of her anterior part of the neck

excessive- swelling of the thyroid gland also lymph node swelling due to infection (anatomical structure of anterior neck/lymph node malignancy)

-hand sweating of three-month duration-hyperhydrosis(primary or secondary,primary-stress,secondary-underlying medical condition,eg-cancer),three month is chronic

-lately became less

tolerant of hot weather.-hormonal endocrine disorder,menopause leads to fluctuation of hormonal level-hyperthyroidism-can increase basal metabolic rate which increases temperature in the body

differential diagnosis

-hyperthyroidism

-thyroiditis-goiter

-cancer

-lymphadenopathy

-trauma

-lymphadenitis-inflammation of lymph node

-thyroglossoduct cyst

-graves disease

-meningitis

further questioning

-socrates;

-site(what specific part of the anterior neck-to differ between lateral or etc),

onset-since when does the swelling start,if sudden then it is likely inflammation

-characteristics-red(how red??oodema??)(radiating or not to differ meningitis or angina)

-associated problems-(hyperhidrosis-irregular heartbaet-difficulty to swallow(problem asssociated hyperthyroidism-increased basal metabolic rate))

-time-episodes of sweating?- 7 days straight to be primary(is it when anxiety to differ anxiety)-day or night(to differ temp related or not)

-exacerbating factor-does pain when taking drugs/eating, painful when swallowing?when eating sppicy food?(hyperhidrosis(induced by capsaicin))(exercising???)

-scale-1 to 10pain or not (to differ severity)

-past medical history-any subsequent trauma injury operation to the neck-any previous medication (have any allergies?)(any comorbidities)(hypertension,diabetes,subsequent throat infection?)

sosial - drugs? smoke? alcohol? where you live? travelling(to differ tropical infection) menstrual cycle (menopause?) occupation, lifestyle/diet/hygiene?

familial history-any family member similar problem cancer? autoimmune disease ,

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pounding - rapid pulse

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she started to feel her heart “pounding” during her low-intensity exercise with easy fatiguability - due to basal metabolic rate increase, may have any heart ds, or thyroid, increase sensitivity of b adrenerguic in heart - cause excessive sweating

lost weight about 11 kg over the past four months, despite having an increased appetite. - due to increase BMR, cause excessive calorie burning leading to lost weight, sleeping difficult due to metabolic changes, hard to relax, symptoms of hyperthyroidism

She also complained of sleeping difficulty at night - sleeping difficult due to metabolic changes, hard to relax.

Past medical history no - first onset of sx, acute onset, not chronic situation- can rule out any carcinoma, mayb any cvs ds

Medications and allergies no - not due to drugs, no past illness, acute, not secondary illness, can rule out any risk factor

no family history of similar illness - not inherited cancer (less likely to get cancer), can be any sporadic AI ds,

Social history no - immunocompetent, no risk factor, not due to alcohol or smoking

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differential diagnosis

-hyperthyroidism

-thyroiditis-goiter

-cancer

-lymphadenopathy

-trauma

-lymphadenitis-inflammation of lymph node

-thyroglossoduct cyst

-graves disease

-meningitis

further investigation

BReHeT- bp, hr (maybe high), rr(increase), temp(mayb increase)

BMI - weight loss (can be due to diet, increase BMR, decrease appetite, calorie deficit, diabetes type 1. adrenal tumor-adrenal insufficiency, pheochromocytoma)

PE

inspection, general observation- body habitus, hyperreflexia, neurological examination - muscle weakness,

palpation of Lymph node (cervical area)- mobile, any mass, pulsatile, solid or liquid, pitting or non pitting

percussion

auscultation

face and neck examination

eye examination - exophthalmos (if graves ds)

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Lid lag- upper eyelid didn't move down as fast as the person look down

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Borderline normal temp, high heart rates, borderline normal respi rate and systolic high BP and borderline diastolic BP

No sign of infection, may have palpitation and cause high systolic BP and high respi for O2 demand due to High Systolic BP

Low BMI from normal range - increase of metabolic rate and lose of weight

Anxious state - hyperthyroidism could induce this state

forward protrusion of the eye in orbit on both sides (exophthalmos), lid lag - bulging of eyeball, symptoms of hyperthyroidism that only occur in Graves Ds, lid lag due to sympathetic overstimulation of the superior tarsals muscle

thyroid gland was enlarged, thyroid was firm in consistency on palpation with an audible bruit over it.

enlarged due to swelling, firm indicating mass, causing compression of blood vessel lay under the thyroid gland causing the brits to be happen/heard

No palpable lymph nodes were revealed- indicating no lymph node infection and inflammation , not related to lymph node in this case

fine bilateral hand tremor and hyperactive deep tendon reflexes- could due to increase in metabolic demand causing overactive/secretion of catecholamines , leading to this symptoms

warm and moist hands-consistent to hyperhidrosis, related to catecholamines that involve in cholinergic pathway

Examination of other systems: Nil of significance - locally at cervical area, most likely only involve endocrine system and organ, specifically thyroid

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differential diagnosis

-graves disease

-hyperthyroidism

-thyroiditis-goiter

-cancer

-lymphadenopathy

-trauma

-lymphadenitis-inflammation of lymph node

-thyroglossoduct cyst

-meningitis

Further Investigation

FBC

TFT

CT SCAN

Serum Antibody Titration

Radioactive iodine uptake

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TSH low, T4 high, Anti-TSH receptor antibodies positive - thyroid problem, not pituitary. positive autoimmune, T4 is high bcs slow conversion from t3 to t4. t4 have high half life

Radioactive iodine scanning and measurements of iodine uptake revealed an increased radioactive iodine uptake. - want to differentiate with thyroiditis (whole - Grave disease, decrease - thyroiditis)

The patient was diagnosed with hyperthyroidism due to Graves’ disease. - diagnosis

The doctor prescribed carbimazole together with a β-Blocker (propranolol) and arranged for a follow-up appointment in four weeks. - medication to treat hyperthyroidism (anti thyroid), beta blocker to control the sympathetic symptoms

\With anti-thyroid medications, the patient's thyroid function test results showed consistent improvement and resolution of patient's hyperthyroidism symptoms. - management

A repeat blood test after three months showed thyroid hormone levels had returned to normal.

She was advised to continue taking anti-thyroid medication for at least 18 months and to come regularly for follow-up. - comply to the drug and positive recovering

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FINAL DIAGNOSIS:

hyperthyroidism due to Graves’ disease