A 35-year-old woman has palpitations, tremor and weight loss with suppressed TSH and elevated free T4. How would you approach this?

Question

Accepted Answer

This is biochemical thyrotoxicosis. My first step is to determine the underlying cause; in a 35-year-old woman common causes are Graves', thyroiditis or a toxic nodular goitre. Focused history: eye symptoms suggestive of Graves', neck pain suggestive of thyroiditis, recent pregnancy, medication history including amiodarone, and family history. Examination for goitre, bruit, ophthalmopathy and severe thyrotoxicosis features. I would request TRAb to support Graves'; if unclear, a radioactive iodine uptake scan may differentiate increased synthesis from thyroiditis. For symptom control I would start propranolol unless contraindicated. If Graves' is confirmed I would initiate carbimazole for typically 12–18 months with TFT monitoring, counselling the patient about agranulocytosis — advising her to seek urgent review and FBC for sore throat, fever or mouth ulcers. Long-term options include continued medical therapy, radioactive iodine or surgery depending on response, preference and recurrence risk.

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