IM12.1-14 | Thyroid Dysfunction — Assignment

CLINICAL SCENARIO

This assignment asks you to work through a structured clinical problem in thyroid disease. You will be given a clinical scenario (below) and asked to complete five sections covering history, TFT interpretation, investigation planning, management, and prescription writing. The purpose is to integrate the clinical evaluation and pharmacotherapy skills from the Thyroid Dysfunction module and demonstrate that you can translate knowledge into a complete clinical management plan for an individual patient.

Clinical scenario: Mrs Kavitha Rajan, a 36-year-old schoolteacher from Chennai, presents to the general medicine outpatient clinic with a 4-month history of palpitations, progressive weight loss of 8 kg despite increased appetite, heat intolerance, and difficulty concentrating at work. She has a 10-year-old daughter with no known thyroid disease. Her menstrual cycles have become irregular over the past 3 months. She takes no regular medications. She reports that her mother had 'thyroid problems' treated with a tablet. On examination: pulse 118/min irregular; BP 134/76 mmHg; thyroid — a diffuse smooth goitre approximately twice normal size with an audible bruit; mild bilateral proptosis with lid lag; fine tremor of outstretched hands; warm moist skin; mild proximal muscle weakness on standing from a chair. TFTs (laboratory report provided): TSH <0.01 mIU/L; FT4 58 pmol/L; FT3 18 pmol/L.

Section 1: Structured History and Examination Findings

Guidance: Document the structured history for this patient under the following domains: (a) presenting complaint and duration; (b) thyrotoxic symptoms — cardiovascular, gastrointestinal, neuropsychiatric, musculoskeletal, reproductive; (c) hypothyroid symptoms to specifically exclude; (d) relevant past history including goitre, neck irradiation, recent iodine exposure; (e) family history of thyroid or autoimmune disease; (f) drug and allergy history; (g) social history including pregnancy status and contraception. Then document the key examination findings as described in the scenario, highlighting the most diagnostically significant findings and naming the examination technique used to palpate the thyroid gland. Approximately 300 words.

Section 2: TFT Interpretation and Differential Diagnosis

Guidance: State what TFT pattern this represents (classify using the standard seven-pattern framework from the module). Construct a prioritised differential diagnosis listing at minimum: your top diagnosis, one alternative cause of overt thyrotoxicosis, and one condition that must be excluded. For each diagnosis on your list: (a) state the clinical and biochemical features that support it, and (b) identify the single most discriminating test that would confirm or exclude it. Approximately 250 words.

Section 3: Investigation Plan

Guidance: Describe your investigation plan in tiers. Tier 1: the screening test and what you expect it to show (already done). Tier 2: the confirmatory tests to characterise the pattern. Tier 3: aetiology-defining tests — which antibodies and/or imaging would you order, and why, for this specific patient? Include: ECG interpretation (what would you expect, and why is it clinically important in this patient?), a targeted CBC order with your rationale, and thyroid ultrasound with Doppler if indicated. State whether RAIU is indicated in this patient and why or why not. Approximately 200 words.

Section 4: Management Plan

Guidance: Propose a complete management plan for Mrs Kavitha Rajan. Include: (a) antithyroid drug selection — state which drug, starting dose, and frequency, and justify your choice given her clinical features; (b) adjunctive therapy — which additional drug class would you add immediately for symptom control, and at what dose? (c) monitoring plan — when will you recheck TFTs, what are you monitoring for, and what are the two most important adverse effects you will counsel her about? (d) definitive therapy — given the clinical features, which definitive option is preferred for this patient and under what circumstances would you refer? (e) special situation: if Mrs Kavitha were 10 weeks pregnant (a different scenario), how would your drug choice change and why? Approximately 350 words.

Section 5: Prescription Writing

Guidance: Write a complete, legally valid prescription for ONE of the following (your choice, aligned to your management plan): (a) the antithyroid drug you selected, or (b) levothyroxine (if Mrs Kavitha had instead presented with overt primary hypothyroidism at TSH 48 mIU/L and FT4 5 pmol/L, cardiac history absent). Include: patient name and age, date, drug name (generic), dose, frequency, duration or indication for review, your name as prescriber, and a specific patient safety instruction. Approximately 100 words.

PEER REVIEW

Review your peer's assignment using the rubric. For each section: assign a score from the rubric, and write one specific sentence explaining the score — do not copy rubric descriptors verbatim. For Section 2: verify that the TFT pattern is correctly classified (suppressed TSH + elevated FT4 + elevated FT3 = overt hyperthyroidism) and that the differential is prioritised not merely listed. For Section 4: check that the pregnancy sub-question correctly identifies PTU as the first-trimester choice and notes the switch to carbimazole in trimester 2 — both elements must be present for full marks. For Section 5: check the prescription format against the five required elements and flag any that are missing. Complete your review within 72 hours of receiving the submission.