General Data

o Name: ACR o Nationality: Filipino

o Age: 27-year-old o Religion: Roman Catholic
o Gender: Female o Occupation: Architect
o Civil Status: Single o Contact Number: 09181234567
o Date of Birth: April 11, 1995 o Source of Information: Patient
o Place of Birth: Bacoor, City herself
o Current Address: Pedro Gil, o Referred by: Office Clinic
Malate, Manila
Chief Complaint: Fast heartbeat
History of Present Illness
Two months prior to consult, the friend of the patient noticed the enlargement of her
neck. The patient denied neck pain, difficulty of breathing, difficulty of swallowing and
voice changes. No management or treatment was done.

One month prior to consult, the patient had a fast heartbeat even at rest, intermittent
in character, and last throughout the day. She also experienced Bilateral Temporal
headaches described as “ kumikirot”, with a grade of 4/10, alleviated by sleep but
eventually goes back. No management or treatment was done. The patient had
unintentional tremors with palpitations that was relieved by rest. She also reported
experiencing heat intolerance and excessive sweating. No consult was done. The
patient denied experiencing the same symptoms before. No difficulty of breathing, no
easy fatigability, no nausea, no dizziness, no vomiting. The patient reported that
drinking coffee worsens her symptoms.

One day PTC, the patient had persistent headaches, tremors, and palpitations.
On the day of consult, she again experienced palpitations and hand tremors which
opted her to seek consult.
Past Medical History
Childhood Illness
o Unrecalled
Adult Illness
Medical
o No diabetes, No hypertension, No Tuberculosis, No asthma,
No hepatitis, No arthritis, No Cancer, No HIV
Surgical
o The patient denied any past surgery
Psychiatric
o No history of psychiatric consultation
Health Screening
o STI Screening (2 months ago)
→ Negative result.
o No Pap smear, No mammograms
Medication Data
o No medications
Injuries/Accident
o No injuries
Transfusions/Reactions
o No blood transfusion
Immunizations
o No vaccination against COVID-19
→ Vaccination scheduled for next month
Allergies
o No known allergies to food and drugs
Family Planning
o No condoms
o Family planning method: Artificial (Oral contraceptive pills)
→ Name: Cyproterone acetate + Ethinylestradiol (Diane-
35)
 → Duration: 2 years
→ Regularly taken: Yes
→ Prescribed: No
Gynecologic
LMP
o April 9, 2022
Menarche: 13 years old
o Interval: Regular
o Duration: 4 days
o Amount of flow: 3 pads per day
o Symptoms: No dysmenorrhea
Coitarche
o 16 years old
Sexual History
o Sexually active
o The patient had 3 sexual partners (1 current sexual partner)
o No dyspareunia

Obstetrics
o Nulligravida

Family Medical History

Family History
o Father: 57 years old, living with hypertension for 17 years
o Medications: Losartan 100mg (good compliance)
o Highest blood pressure: 140/ 90 mmHg
o Mother: 55 years old, living with hypertension for 7 years
o Medications: Losartan 50mg (good compliance)
o Highest blood pressure: 130/90 mmHg
o Sister: 30 years old, no medical condition
 o No known illnesses such as thyroid related illness, Tuberculosis,
cancer, diabetes, cardiac related illness

Current Health of Parents and Siblings

o Immunizations
o Vaccinated against COVID-19
 Complete doses (2 doses)
 Brand: AstraZeneca
 No reported reactions
 No booster
Genogram

Personal and Social History

Single, but in a relationship with her boyfriend. Has been living for two years in a
one-bedroom corner unit in University Tower Malate, Manila with one bathroom and two
big windows, which she shares with her boyfriend. Denied any nearby river, factories,
or dumpsites.
 The patient reported to have 4-6 hours of sleep per night but described it as a not
restful sleep. No insomnia and denied snoring. The patient had 3 sexual partners. She
and her partner doesn’t use condoms but she self-medicated with oral birth pills (Diane-
35), daily for 2 years.
She is an occasional alcoholic beverage drinker consuming 1-2 bottles of beer
only. She is a non-smoker and denied use of illicit drug. Does yoga every weekend for
30minutes to 1 hour. Her diet includes carbohydrates, fish, vegetables, meat, and
coffee. Not fond of eating salty foods and drinking soft drinks.
She is currently employed as an architect for 2 years. Denied other source of
income. The patient have a sister who works as a fashion designer which provides
financial support to her. Denied any recent travel history.

Review of Systems
o General: no areas of inflammation, no fever, no change in sleeping
pattern, no pain
o Cutaneous: (+) Warm to touch, no itchiness, no redness
o Head: no thinning of hair, no lumps
o Eyes: no itchiness, no inflammation, no discharge, no pain, no visual
impairment, no photosensitivity, no diplopia.
o Ears: no discharge, no pain, no tinnitus, no balance problem
o Nose: no discharge, no pain, no epistaxis, no loss of smell, no
congestion
o Mouth/Throat: no bleeding, no ulcers, no lesions, no pain, no loss of
taste, no dry mouth, no sore throat, no hoarseness in voice.
o Neck: no neck pain, supple neck
o Breast: no lumps, no masses, no pain, no discharge, no discolorations
o Cardiac: no nocturnal dyspnea, no chest pain
o Respiratory: no wheezing, no dyspnea, no cough.
o Gastrointestinal: no diarrhea, no abdominal or rectal masses
o Genitourinary: no dysuria, no flank pain, no hematuria
 o Neurologic: no motor impairments, no memory impairments, no
syncope
o Hematologic: no bruising, no abnormal bleeding, no pallor
o Vascular: no discolorations of extremities, no variceal swelling, no
swelling of extremities.
o Musculoskeletal: no difficulty in walking, no muscle weakness
o Psychiatric: no depression, no suicidal ideation
Physical Examination
General Survey
o The patient is conscious and ambulatory with a GCS score of 15. She
can speak in sentences, comfortable and has an upright posture.
No apparent body movement, has a symmetrical body, no
characteristic facies. Patient looks moderately ill and is dress
appropriately with age and well groomed. Appropriate mood and
affect, intact thought process, intact immediate, recent, and remote
memory.
Vital Signs
o Weight- 58kg
o Height- 165cm
o BMI: 21.3 kg/m2 (Normal)
o Palpatory BP-130/ 80 mmHg
o Auscultatory BP- 130/80 mmHg
o Temperature- 37℃
o Heart Rate- 109 bpm
o Respiratory Rate- 16 cpm
o O2 status- 99%
Skin
o Fair, no lesions, warm to touch
HEENT
o Head:
 o Inspection: Normocephalic, Face is symmetrical.
o Palpation: No mass, no tenderness
o Eye: Black, palpebral conjunctiva are smooth, pink, shiny. Sclera is
non-icteric. Visual Acuity is 20/20. Pupillary light reflex is 2-3 mm,
equally briskly reactive to light and accommodation. Extraocular
muscles have full range of motion. In fundoscopy, there is positive red
orange reflex
o Ear: Normal and symmetrical auricle, no discharge, no inflammation,
positive whisper test. Tuning fork test is normal (BC>AC). In otoscopy,
positive cone of light.
o Nose/ Throat: Symmetrical, no deformities, pinkish mucosa.
Paranasal sinuses are non-tender.
o Mouth: Chapped lips, pink gums, no dental carries. Tongue is at the
midline, soft palate elevates symmetrically, posterior oropharynx is non
hyperemic, no enlargement of tonsils and no oral ulcers.
o Neck: Upon inspection there is a 7x3cm diffusely enlarged thyroid
gland that moves with deglutition. On palpation, there is no palpable
lymph adenopathy on both sides. Trachea is in the midline. Upon
auscultation, there is the presence of thyroid bruits on bilateral
sides. There is full range of motion on cervical spine, no pain on
movement.

Respiratory
o Inspection: No lesions, symmetric chest anteriorly and posteriorly, AP<
Transverse diameter
o Palpation: symmetrical and equal chest expansion, no tenderness,
equal tactile fremiti on both sides
o Percussion: Resonant on bilateral hemithorax
o Auscultation: Bronchovesicular breath sounds bilaterally, anteriorly,
and posteriorly. No adventitious breath sounds. Equal vocal fremiti.
 Cardiac
o Inspection: Adynamic precordium. JVP not measured but engorged.
No carotid bruits.
o Palpation: PMI at 5th ICS LMCL, no heaves, no lifts, no thrills.
o Auscultation: Normal S1 and S2, Tachycardic but regular rhythm,
S1>S2 at the base, S2>S1 at the apex
Abdominal
o Inspection: Flat and symmetrical
o Auscultation: Normoactive bowel sounds
o Percussion: Tympanitic on all four quadrants, Liver is 6cm, Spleen and
kidneys are not felt, Negative CVA, non-palpable urinary bladder
o Palpation: Abdomen is soft, non-tender, no hepatosplenomegaly
GUT/ Rectal
o Refused by patient
Musculoskeletal
o Full range of motion on all extremities. Good motor strength (5/5). (+)
Unintentional tremors on both hands.

Salient Features
General Data Age: 27 y/o
Gender: Female
Occupation: Architect
Chief Complaint Fast Heartbeat
History of Present Illness 2 months prior to consult:
o Enlargement of neck
o No neck pains
o No difficulty in neck movement
o No difficulty in swallowing
o No difficulty in breathing
o No voice changes
 o Increase urinary frequency
o Easy irritability
1 month prior to consult
o Palpitations persisted
o No treatment/ management
done
o (+) Hand Tremors
o Relieved at rest
o (+) Bilateral temporal headache
while having palpitations
o Described as “kumikirot”
o 4/10
o Alleviated by sleep but
comes back
o No medications taken
o (-) dizziness, (-) no nausea, (-)
vomiting
o (+) Weight loss (undocumented)
o (+) Heat intolerance
o (+) Excessive sweating
1 Day PTC
o Persistent headaches
o Palpitations
o Hand tremors
On the day of consult
o Palpitations
o No headache
o Hand Tremors
Past Medical History STI screening
o 2 months ago
o Negative results
Immunizations: No COVID-19 vaccine
Family planning method
o Oral contraceptives
o Diane-35
Family Medical History o Father: (+) Hypertension
o Losartan 100mg/day
o Mother: (+) Hypertension
o Losartan 50mg/day
Personal and Social History Diet
o (-) Salty foods
o Coffee drinker
o 6 cups/ day reduced to 4
cups/day
Non-smoker
Occasional Alcoholic drinker
Exercise
o Yoga
o Every weekend
o 30 mins to 1 hour
Sleep
o 4-6 hours
o Tiredness upon waking up

Review of Systems Cutaneous: (+) feels hot to touch

Physical Examination Vital Signs
o Weight- 58kg
 o Height- 165cm
o BMI: 21.3 kg/m2 ( normal)
o Palpatory BP-130/ 80 mmHg
(Stage 1 HTN)
o Auscultatory BP- 130/80 mmHg
(Stage 1 HTN)
o Temperature- 37℃
o Heart Rate- 109 bpm
(tachycardic)
o Respiratory Rate- 16 cpm
o O2 sat- 99%
o (+) Chapped lips
o (+) 7x3cm diffusely enlarged
thyroid gland that moves with
deglutition
o (+) thyroid bruits on bilateral sides
o (+) JVP not measured but
engorged

Primary Working Impression

Primary Hyperthyroidism secondary to Diffuse Toxic Goiter/Grave’s Disease

Rule In Rule Out

(+) Diffuse goiter with bruit (-) Exophthalmos
(+) Age (-) Frequent bowel movements
(+) Gender (-) Muscle weakness
(+) Work induced stress (-) Increased appetite
(+) Anxiety (-) Proximal muscle weakness
(+) Excessive sweating (-) Dyspnea
(+) Heat intolerance (-) Reduction in menstrual flow
 (+) Palpitations
(+) Tremors on both hands
(+) Tachycardia
(+) Weight loss
(+) Irritable
(+) Increase urinary frequency
Graves’ disease is a hypermetabolic condition produced by circulating IgG
antibodies that bind to and activate the G-protein–coupled thyrotropin receptor.
Follicular hypertrophy and hyperplasia are stimulated by this activation, resulting in
thyroid enlargement and increased thyroid hormone production. The hyperthyroidism of
Graves’ disease is caused by thyroid-stimulating immunoglobulin (TSI) that are
synthesized in the thyroid gland as well as in bone marrow and lymph nodes, thereby
causing the stimulation of thyroid hormone synthesis and secretion which will cause
thyroid growth. Such antibodies can be detected by bioassays or by using the more
widely available thyrotropin-binding inhibitory immunoglobulin (TBII) assays. The
presence of TBII in a patient with thyrotoxicosis implies the existence of TSI. Indirect
evidence suggests that stress is an important environmental factor, presumably
operating through neuroendocrine effects on the immune system.

Differential Diagnosis
1. Toxic Thyroid Adenoma
Rule In Rule out
 Young adult age (-) Proximal muscle weakness
Female (-) Lid lag
(+) 7x3 cm diffusely enlarged thyroid (-) Diarrhea
gland (-) Increased appetite
(+) Weight loss (-) Dysphagia
(+) Tachycardia (-) Dyspnea
(+) Palpitations (-) Flushing
(+) Tremor (-) poor sleep
(+) Irritable
(+) Anxiety
(+) Stress
(+) Tiredness upon waking up
(+) Skin is warm to touch
BP- 130/80mmhg
Hyperthyroidism is caused by a toxic thyroid nodule (an overactive
thyroid). When a single nodule (or lump) forms on the thyroid gland, it causes it
to expand and release too much thyroid hormone. Toxic adenoma occurs when
an increase in hormone production is caused by a single nodule in the gland.

2. Anxiety disorder
Rule In Rule Out
(+) Tremors (-) History of psychiatric disorder
(+) Irritability (-) Family history of psychiatric
(+) Urinary Frequency disorder
(+) Warm flushes/ Heat intolerance
(+) Restlessness upon waking up
(+) Headache
(+) Palpitations
(+) Work related stressors

An interplay of biopsychosocial variables appears to be the cause of

anxiety disorders. Clinically significant syndromes are produced when genetic
 vulnerability interacts with stressful or traumatic events. Norepinephrine,
serotonin, dopamine, and gamma-aminobutyric acid are regarded to be important
anxiety mediators in the central nervous system (GABA). Most symptoms are
mediated by the autonomic nervous system, particularly the sympathetic nervous
system.
The amygdala is responsible for regulating fear and anxiety. An increased
amygdala response to anxiety stimuli has been discovered in patients with
anxiety disorders. Prefrontal cortical regions are related to amygdala and limbic
system structures, and prefrontal-limbic activation imbalances can be rectified by
psychological or pharmaceutical therapies.

3. Pheochromocytoma
Rule In Rule Out
(+) Tremors (-) adrenal affectation
(+) Headache (-) pallor
(+) Palpitations (-) constipation
(+) Excessive sweating (-) vomiting
(+) Tachycardia (-) generalized weakness
(+) Weight loss (-) shortness of breath
(+) Stress (-) dizziness
(+) Anxiety (-) abdominal/chest pain
(+) BP= 130/80mmHG (-) flushing
(-) visual disturbance
(-) nausea
RR = 16 bpm
 Excess catecholamine secretion by the tumor causes the clinical signs of
a pheochromocytoma. Intermittent or continuous secretion are possible.
Norepinephrine and epinephrine are the most common catecholamines
produced, however certain tumors also generate dopamine. Catecholamine
secretion is not regulated in the same way in pheochromocytomas as it is in
healthy adrenal tissue. Pheochromocytomas, unlike the healthy adrenal medulla,
are not innervated, and catecholamine production is not triggered by brain
stimulation. Although the exact cause of catecholamine release is unknown,
several theories have been proposed, including direct pressure, medicines, and
changes in tumor blood flow.

Concept Map of PWI

References:

o Harrison’s Principles of Internal Medicine 20th ed

o Society of Endocrinology. (2022). Toxic thyroid nodule. You and your hormones.
Retrieved from : https://www.yourhormones.info/endocrine-conditions/toxic-
thyroid

o Anxiety disorders. In: Diagnostic and Statistical Manual of Mental Disorders

DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013.
http://dsm.psychiatryonline.org. Accessed May 6, 2022
o Mayo Clinic. (2022). Anxiety Disorders. Retrieved from:
https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-
20350961
o Blake, A. (2021). Pheochromocytoma. Retrieved from:
https://emedicine.medscape.com/article/124059-overview#a4