CASE STUDY 16 - Sonia Dawson

Sonia Dawson, a 30-year-old female, has been diagnosed with Graves disease. She has recently lost 25 pounds despite an increased appetite. Her vision is blurry; her heart races and pounds. She has been irritable but attributes the irritability to insomnia. She has had bouts of diarrhea. She feels hot, even if others are comfortable. The collars on her clothing are becoming too tight. Her last menstrual period was 2 months ago. Before that time her menses were regular.
On physical examination, the nurse notes that Ms. Dawson is thin, pale, and anxious. She moves restlessly around the room. Her eyes are bulging and have a staring appearance. Her eyelids and hands have fine tremors. Her skin is smooth, warm, and moist. She is sweating profusely, although the room temperature is ambient. Her hair is very fine and soft. She weighs 112 pounds. Her oral temperature is 99° F (37.2° C), heart rate is 120 beats/min at rest, respirations are 20/min, and blood pressure is 110/50. Her thyroid gland is enlarged with auscultation of a bruit. Laboratory results reveal a serum T3 level of 200 mcg/dl (high), a T4 level of 20 mcg/dl (low), and a TSH level that is 2.5 μU/ml, which is normal. A thyroid antibody test shows a high titer of thyroglobulin antibodies. Radioactive iodine uptake test shows a 40% uptake in 6 hours, which is elevated.
The decision to treat nonsurgically is made. Ms. Dawson is started on methimazole, 10 mg by mouth every day, to suppress her thyroid gland and propranolol, 10 mg twice each day, to decrease her heart rate and control her cardiac symptoms.