Pediatric Graves Disease: Lessons for Primary Care

Scott A. Rivkees, MD


March 18, 2011

In This Article

A Moody Teenager or Something More?

Rasheeda, an 11-year-old black girl new to your practice, presents on a busy August morning for a preparticipation exam. She is about to begin sixth year at a local middle school and plans to try out for the soccer team. Her mother reports that she has played soccer competitively since 6 years of age although she is reported to have had "a tough time" during her summer league and was noted to be more tired and less tolerant of the heat than in the past. Although her previous growth records are not available her mother has noted that she has "really spurted" in the last 6 months and that "all of her pants" are too short. She is reported to be eating "constantly." Both she and her mother believe she that is thinner although they are uncertain whether she has lost weight or whether her slimmed-down appearance is the result of height growth.

Although she had been a strong student her grades slipped during the fifth grade. Her mother notes that "the teens have arrived" and describes her daughter as moody and easily distracted over the last year. Rasheeda states that she feels "nervous" and "worries a lot" about starting high school.

Both Rasheeda and her mom describe her as a "night owl." The child reports that she wakes frequently at night and has trouble returning to sleep. Upon questioning she notes that she urinates "a couple of times" during the night but is uncertain whether that is the reason she awakens.

Physical Exam

On exam she is noted to be tall and thin with a body mass index of 18 kg/m2. She is unable to recall her last menstrual period but notes that she achieved menarche approximately 1 year earlier and has had "maybe" 5 or 6 periods, which are described as variable in duration and amount of bleeding.

Head: normocephalic
Eyes: Eyes are slightly protuberant but without obvious exophthalmos; full extraocular movements; retinal exam unremarkable
Ears: normal size, shape, tympanic membranes pearly
Nose: unremarkable
Throat: pharynx pink, without exudates; neck supple with no palpable adenopathy; thyroid symmetrically enlarged
Respiratory: regular respiratory rate; breath sounds full, equal, clear bilaterally
Cardiac: heart rate is 96 beats per minute at rest and regular without clicks or murmur; precordium is quiet
Abdomen: abdomen flat, soft, nontender without masses
Musculoskeletal exam: symmetric bilateral muscle mass and tone with good equal strength
Neurologic exam: cranial nerves II through XII grossly intact, deep tendon reflexes brisk and equal bilaterally
Skin: pink, warm, moist


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