Don't Forget the Thyroid: Graves' Disease

PRESENTATION An atypical presentation can confound the diagnosis, and that is what happened when a 33-year-old African-American woman presented to another hospital with a 3-month history of worsening abdominal pain. She had been in good health until she started experiencing persistent abdominal pain and distension associated with nausea, vomiting, loose stools, decreased appetite, and weight loss. Her past medical history was significant for an episode of deep venous thrombosis during pregnancy and an unevaluated thyroid nodule. She had no history of heavy alcohol or intravenous drug use, and her family history was unremarkable. Unemployed, she was taking classes at the local community college. Her clinical picture at the outside hospital was consistent with liver disease. The patient’s initial physical examination showed jaundice, abdominal distension and tenderness, and a positive