A 26-year-old woman enjoyed good past health but presented with involuntary weight loss, palpitations, and shortness of breath on exertion for 1 month. She had no known drug allergy. Physical examination revealed atrial fibrillation (heart rate 140 beats per minute) and signs of heart failure such as peripheral edema and basal lung crepitation. She had proptosis and exophthalmos which were suggestive of thyrotoxic eye disease. The blood investigations revealed the following results: 

• Thyroid stimulating hormone (“TSH”) <0.03 mIU/L (Reference range: 0.27 – 4.2 mIU/L) 

• Free T4 102 pmol/L (Reference range: 12 – 22 pmol/L) 

• Total bilirubin 16 umol/L (Reference range: <17 umol/L) 

• Alkaline phosphatase 152 U/L (Reference range: 33 - 84 U/L) 

• Alanine aminotransferase 98 U/L (Reference range: < 47 U/L) 

(a) Suggest FOUR DRUGS and their ADVERSE EFFECTS for the 

treatment of atrial fibrillation and heart failure in thyrotoxicosis. 

(8 marks) 

(b) As the patient has liver impairment, discuss if methimazole or propylthiouracil is a better anti-thyroid drug option. (2 marks) 

(c) Name ONE rare but potentially fatal adverse effect of anti-thyroid drugs. What symptoms would you teach the patient to recognize the occurrence of this condition? 

(2 marks) 

(d) The patient being treated with an anti-thyroid drug becomes pregnant. How would you recommend the anti-thyroid drug (“ATD”) therapy during pregnancy? 

(4 marks) 

(e) The patient has relapse of thyrotoxicosis after discontinued ATD therapy 2 years later and decides to receive radioactive iodine therapy. Instruct the patient about post-treatment precautions on radiation safety to reduce exposure to others. 

(4 marks)