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Let’s start our USMLE Review with Hypothyroidism and Hyperthyroidism from the Gold Standard USMLE Foundations of Medicine Audio Review program.
Play USMLE Audio MP3 11 13 Differential Diagnosis of Graves’ Disease Below
Begin 11 13 Differential Diagnosis of Graves’ Disease Transcription
Differential diagnosis for Graves’ disease can be problematic because the disease sometimes presents in an atypical manner.
For example, marked muscle atrophy may suggest severe myopathy, which needs to be differentiated from which other kind of disorder?
Myopathy is differentiated from primary neurologic disorder.
Thyrotoxic periodic paralysis presents with a sudden attack of flaccid paralysis and hypokalemia.
Which patient demographic population does it most often occur in?
- Thyrotoxic periodic paralysis occurs most often in Asian males. The paralysis usually subsides spontaneously on treatment of thyrotoxicosis and can be prevented by two measures.
What are they?
- Thyrotoxic periodic paralysis can be prevented with potassium supplementation and beta blockers. Patients with thyro-cardiac disease present mainly with high output heart failure or with which other symptom of heart involvement. Thyro-cardiac disease often presents with refractory atrial fibrillation insensitive to digoxin. About half of these patients have no evidence of underlying heart disease.
Some older Graves’ disease patients present with weight loss, small goiter, slow atrial fibrillation and severe depression.
This syndrome of symptoms in these placid patients is known by what name?
- Apathetic hyperthyroidism.
Some younger female Graves’ disease patients may present with amenorrhea or infertility as the primary complaint. How will these patients be diagnosed as hyperthyroid?
- The diagnosis can be made based on clinical and lab findings.
A final differential diagnosis will name for Graves’ disease involves an abnormal albumin-like serum protein that binds T4 but not T3.
What is this abnormal Thyroxine condition?
- Familial Disalbuminemic HyperThyroxinemia.
This euthyroid condition can be differentiated from hyperthyroidism by the absence of clinical features and by two normal serum levels which exclude hyperthyroidism.
What are the two levels?
- A normal T3 and TSH.
Student doctor please pause the tape and summarize the differential diagnosis of Graves’ disease. Please include myopathy, thyrotoxic periodic paralysis, thyro-cardiac disease, apathetic hyperthyroidism, and Familial Disalbuminemic HyperThyroxinemia in your summary.
- Graves’ disease sometimes present in an atypical manner making differential diagnosis difficult. Marked muscle atrophy may suggest severe myopathy which must be differentiated from primary neurologic disorder. Thyrotoxic periodic paralysis usually occurs in Asian male patients and presents with a sudden attack of flaccid paralysis and hypokalemia. Symptoms resolve with treatment of thyrotoxicosis and can be prevented with potassium supplementation and use of beta blockers. Patients with thyro-cardiac disease primarily present with high output heart failure or refractory atrial fibrillation insensitive to digoxin. Half of these patients display no evidence of underlying heart disease and their cardiac problems are resolved with treatment of thyrotoxicosis. When older, placid appearing patients present with weight loss, small goiter, slow atrial fibrillation, and severe depression with no clinical features of increased catecholamine reactivity. The syndrome is known as apathetic hyperthyroidism. Birthing age female patients may present with amenorrhea or infertility as the primary symptom. Diagnosis of hyperthyroidism and Graves’ disease is made on the basis of clinical and lab studies in those cases. Familial Disalbuminemic HyperThyroxinemia is a syndrome involving an abnormal albumin-like serum protein which binds to T4 but not to T3. This euthyroid syndrome is differentiated from hyperthyroidism by the lack of hyperthyroid clinical features and by normal serum T3and TSH levels.
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