Presenting Complaints

• The patient presents with a 3-month history of feeling excessively hot, even in cool environments.

History of Presenting Complaint

• The patient reports feeling hot and sweating profusely, even when the ambient temperature is comfortable.
• She notes that she has been feeling more fatigued and has had difficulty concentrating at work.
• The patient denies any recent fever, chills, weight loss, or changes in appetite.

Significant Positives & Negatives For Differentials

Graves' Disease

Positives:

• Symptoms of heat intolerance, excessive sweating, and fatigue
• Family history of thyroid disorder (mother with hypothyroidism)
• Elevated free T4 and free T3 with suppressed TSH
• Presence of thyroid-stimulating immunoglobulins (TSI)
• Diffuse goiter on physical exam or thyroid ultrasound

Negatives:

• Absence of ophthalmopathy or dermopathy
• No recent history of radioiodine therapy or thyroidectomy

Toxic Nodular Goiter

Positives:

• Presence of a palpable thyroid nodule(s)
• Elevated free T4 and free T3 with suppressed TSH
• Heterogeneous appearance of the thyroid on ultrasound
• Increased radioiodine uptake in the nodule(s) on nuclear imaging

Negatives:

• Absence of family history of thyroid disorders
• No recent history of thyroid surgery or radioiodine therapy

Subacute Thyroiditis

Positives:

• Sudden onset of symptoms
• Presence of a tender, enlarged thyroid gland
• Elevated inflammatory markers (ESR, CRP)
• Transient hyperthyroidism followed by hypothyroidism

Negatives:

• Absence of palpable thyroid nodules
• No history of recent viral illness or upper respiratory infection

Pheochromocytoma

Positives:

• Episodic symptoms of heat intolerance, sweating, and fatigue
• Presence of hypertension or labile blood pressure
• Elevated catecholamines or metanephrines in urine or plasma

Negatives:

• Absence of other symptoms like headaches, palpitations, or weight loss
• No family history of pheochromocytoma or multiple endocrine neoplasia (MEN) syndromes

Carcinoid Syndrome

Positives:

• Flushing, sweating, and gastrointestinal symptoms
• Elevated serotonin or 5-HIAA levels in urine
• Presence of a neuroendocrine tumor on imaging

Negatives:

• Absence of diarrhea, wheezing, or valvular heart disease
• No history of a known primary neuroendocrine tumor

Past Medical History

• The patient has no significant past medical history.
• She has not had any prior surgeries or hospitalizations.

Drug/Medication History

• The patient takes no regular medications.
• She denies using any over-the-counter supplements or herbal remedies.

Social History

• The patient is a non-smoker and does not consume alcohol.
• She works as an office administrator and lives with her boyfriend in a flat in London.

Family History

• The patient's mother has a history of hypothyroidism, for which she takes levothyroxine.
• There is no family history of thyroid disorders, autoimmune conditions, or endocrine tumors.

Systems Review

• Positive for excessive sweating, feeling hot, and fatigue.
• Negative for unintentional weight loss, changes in appetite, tremors, or palpitations.
• Denies any changes in bowel or bladder habits, vision changes, or skin abnormalities.

Ideas, Concerns & Expectations

• The patient is concerned that her symptoms may be related to a thyroid disorder, as her mother has hypothyroidism.
• She is worried that the heat intolerance may be impacting her work performance and quality of life.
• The patient hopes the doctor can determine the underlying cause of her symptoms and provide appropriate treatment.

Case Presentation

Based on the patient's presenting symptoms, family history, and the key positives for Graves' disease, the most likely diagnosis is Graves' disease. The student should recommend further workup, including thyroid function tests (TSH, free T4, free T3), thyroid autoantibodies, and potentially imaging studies like a thyroid ultrasound or radioiodine uptake scan to confirm the diagnosis and rule out other potential causes.