The importance of thorough history taking

Case history

A 4-year-old girl, referred to the Paediatric Assessment Unit by the GP, with a 2-week history of a cough, feeling unwell, and tired. Accompanied by her mother.

Read the patient information below and answer Question 1.

Early history

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Early history

  • Born at term in the UK
  • Family are from Bangladesh

Health and medication history

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Health and medication history

  • Coughing a lot – nothing is helping
  • Feeling tired
  • Not vomiting when coughing, no haematemesis
  • Not eating or drinking well
  • No pyrexia
  • No concerns with bowels or passing urine

School history

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School history

  • No medical history, never been in hospital
  • Not on any prescribed medication
  • Using over-the-counter cough mixture, although it has not helped
  • No herbal medication, no medication sourced from the internet, no access to recreational drugs
  • Immunisations up to date – including BCG (offered in the UK in high-risk areas)
  • Had chickenpox last year
  • Family live in East London, known as a high-risk area with increased prevalence of tuberculosis
  • No recent foreign travel, although paternal uncle has just returned from Bangladesh

Family history

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Family history

  • Reception year at primary school
  • Doing well
  • Has lots of friends
  • Mother has type 2 diabetes
  • Maternal grandmother has an underactive thyroid
  • Mother is 153 cm
  • Father is 169 cm

On examination

Temperature 36.8°C
Heart rate 120 bpm
Respiratory rate 20 per min
O2 saturations in air 98%
Blood pressure on right arm 90/60 mmHg
Capillary refill time (CRT) Less than 2 seconds
Height 112 cm (75th centile)
Weight 17 kg (10th centile)
  • Her ears, nose and throat are clear, but she is clammy and sweaty.
  • There is no increased work of breathing, with good air entry, but there is a slight wheeze bilaterally and she has swollen cervical lymph nodes.
  • She has no dysmorphic features, no goitre and is cardiovascularly stable but is tachycardic.
  • She is tall for her age in comparison to her parents.

Concluding the history

Mother concerned about the cough.

Thinks she has a cold.

On asking if there was anything else, mother feels she may have been a bit more sweaty in the last few weeks, but was not concerned.

Question 1.

What would your differential diagnoses be?

  • Endocarditis
  • Hyperhidrosis
  • Upper respiratory tract infection
  • Phaeochromocytoma
  • Tuberculosis
  • Hyperthyroidism
  • Endocarditis
  • Hyperhidrosis
  • Upper respiratory tract infection
  • Phaeochromocytoma
  • Tuberculosis
  • Hyperthyroidism

Question 2.

Which clinical signs or symptoms are making you suspicious?

  • History of cough
  • Tall stature
  • Low weight
  • Sweating
  • Tachycardia
  • Family foreign travel
  • Geographical area
  • Lethargy
  • Doing well at school
  • Family history of thyroid disease
  • Tuberculosis risk
  • Family recent foreign travel
  • Chickenpox history
  • Tall stature
  • Sweating
  • Tachycardia
  • Family history of thyroid disease

Question 3.

Which laboratory tests and investigations do you are think are needed to reach your definitive diagnosis?

  • Sputum sample
  • Naso-pharyngeal aspirate
  • Lung spirometry
  • Stool sample
  • Urine sample
  • Blood cultures
  • Chest X-ray
  • ECG (electrocardiogram)
  • Full blood count (FBC)
  • C-reactive protein (CRP)
  • Urea & electrolytes (U&E)
  • Liver function tests (LFT)
  • ESR (erythrocyte sedimentation rate)
  • 24 hr urine collection for catecholamines
  • Thyroid function tests
  • Thyroid ultrasound
  • Mantoux test

Chest X-ray. ECG (electrocardiogram). Full blood count (FBC). C-reactive protein (CRP). Urea & electrolytes (U&E). Liver function tests (LFT). ESR (erythrocyte sedimentation rate). 24 hr urine collection for catecholamines. Thyroid function tests. Thyroid ultrasound. Mantoux test

Testing

Investigation and rationale Result
Chest X-ray
To look for evidence of tuberculosis: consolidation in upper lobes of the lung, because of history of cough
Clear
Electrocardiogram
To explore cause for tachycardia, and signs of electrical activity in the heart
Normal, with slight tachycardia
Bloods: FBC, U&E, LFT, CRP, ESR
To rule out signs of infection, anaemia, renal disease, liver disease, and raised ESR as seen in endocarditis
All within normal limits
Result Normal range
Hb 129 g/L 110-140
WBC 11.9 x 10 ^9/L 5-15
Platelet 285 x10 ^9/L 200-490
ESR 2 mm/hr 1-12
Na 140 mmol/L 133-136
K 5.1 mmol/L 3.5-5.3
Cl 100 mmol/L 95-105
Urea 5.9 mmol/L 2.5-7.8
Creatinine 30 µmol/L 23-37
Mantoux
Tuberculin skin test for identifying M. tuberculosis infection
Negative

Further endocrine investigations

Investigation and rationale Result
Thyroid function tests
To look for abnormal levels of thyroid hormones
Abnormal thyroid function test results

Free T4 26.7 pmol/L 10.5-24.5
Free T3 10.1 pmol/L 3.1-6.8
TSH 0.01 munit/L 0.27-4.2

Thyroid ultrasound
To look for diffuse thyroid enlargement
Enlarged thyroid, but no focal nodules
Urinary collection for catecholamines
To rule out excess catecholamine release from a pharchromocytoma
Within normal limits (Priesemann et al. 2006)

Question 4.

Which diagnoses are confirmed or refuted?

  • Endocarditis
  • Upper respiratory tract infection
  • Hyperhidrosis
  • Phaeochromocytoma
  • Tuberculosis
  • Hyperthyroidism

Hyperthyroidism

Question 5.

Which further blood test could be performed to further refine the diagnosis?

  • Thyrotrophin-releasing hormone (TRH) test
  • Combined insulin tolerance/TRH/gonadotrophin-releasing hormone test
  • Thyroid-stimulating hormone (TSH) receptor antibodies

Thyroid-stimulating hormone (TSH) receptor antibodies

Results

TSH receptor antibodies 0.84 miU/L (normal range 0.0–0.4)

Consistent with Graves’ disease

Management and follow-up

Referral made to the paediatric endocrinology services for management

Question 6.

What is your management plan and in what order would you do this?

  • Commence antithyroid drug, carbimazole
  • Refer to nurse-led paediatric endocrine clinic
  • Refer for radioactive Iodine therapy
  • Refer to surgical team for thyroidectomy
  1. Commence antithyroid drug, carbimazole
  2. Refer to nurse-led paediatric endocrine clinic
  3. Refer for radioactive Iodine therapy
  4. Refer to surgical team for thyroidectomy

How can raised levels of TSH receptor antibodies manifest clinically? What else do increased thyroid hormones do?

Hover to view our thoughts
Increased levels can stimulate alpha and beta adrenergic receptors in the nervous system. This leads to increased catecholamine release, which results in tachycardia and sweating. Excess thyroid hormones influence epiphyseal maturation, therefore resulting in advanced growth.

Conclusion

Shared care was planned with the patient’s GP, for them to repeat prescriptions of carbimazole, 5 mg once daily. A further outpatient appointment was offered for 2 weeks’ time with repeat thyroid function test. Parental understanding needed to be ensured, so a referral was made to the nurse-led thyroid clinic for further education and support.

No treatment was needed for the cough, which self-resolved.

This case shows that thyroid symptoms can be subtle and easily missed. It underlines the importance of detailed history-taking and clinical examination, and shows that sometimes the presenting complaint can be misleading.

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Meet the author

Kate Davies

Children’s Nursing, UK

kate-davies-1by1
Martin Savage
Programme Director

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