Review Question - QID 108521

Grave's disease presents with weight loss, sinus tachycardia, tremulousness, and sweating. The best initial step in management is to administer propranolol.

Grave's disease occurs due to thyroid stimulating immunoglobulins (TSI's) binding to TSH receptors causing excess thyroid hormone release. TSI's can also cause key findings of proptosis and preorbital fibroblast proliferation leading to exophthalmos. It is these findings in this case that make the diagnosis Grave's disease. The best initial therapy is propranolol followed by propylthiouracil. Definitive therapy is radioactive thyroid ablation though this is contraindicated in pregnancy (fetal hypothyroidism and cretinism). The definitive treatment of Grave's disease in pregnancy is surgical thyroidectomy if medical therapy fails.

Figure A is an EKG demonstrating sinus tachycardia. Note the P-waves that are present differentiating it from supraventricular tachycardia (SVT).

Incorrect Answers:
Answer 1: Vagal maneuvers are the best initial step in management in supraventricular tachycardia (SVT), which would present with an EKG that does not have P-waves and typically a pulse > 200/minute.

Answer 2: If vagal maneuvers fail in SVT the next step in management is to administer adenosine.

Answer 4: Propylthiouracil is the next best step in management after propranolol has been administered in Grave's disease.

Answer 5: Synchronized cardioversion would be the next best step in management if the patient's vitals were unstable and they were presenting with a condition such as SVT. It has no indication in Grave's disease in a patient with stable vitals.

Bullet Summary:
Grave's disease presents with tachycardia, sweating, weight loss, tremulousness and also has key findings of proptosis and exophthalmos. The best initial step in management is propranolol followed by propylthiouracil. The definitive therapy is radioactive thyroid ablation though surgical removal of the thyroid may be indicated in some cases such as pregnancy.