18-08-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS
WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[21-08-2025 11:50] PPM 1: @PPM3 can you have a telephonic session with the patient advocate here to collect an event timeline as well as the clinical and investigation images at a time of mutual convenience?
[21-08-2025 12:02] PA: I will be free "tomorrow between 7-10 in the morning and post 6PM in the evening "to provide the required information.
[21-08-2025 14:40] PPM 3: will do sir
[21-08-2025 14:40] PA: Noted
[29-08-2025 08.04] PA: This is the report 2 days before coming to the hospital
[29-08-2025 08:08] PA: Symptoms before Carbimazole
1. Dull pain in stomach while standing or sleeping (October)
2. Pain got increased at nights after having beef for consecutive 4days, blood after stool (November)
3. Started going to washroom 2-4 times a day with pain in the intestine
4. Lost weight from 62 to 50
5. Feels dizzy and exhausted all the time
6. Used to play cricket for hours without even having food now can't even play 10 mins at any moment
7. Sweats a lot even after any simple work
8. I feel like resting on the bed after standing 3-4 mins
9. Heartbeat increases after any little work, and is usually high while resting
10. Can't stand for a few mins
11. Pain in the knees while standing, climbing or getting down on stairs
[29-08-2025 08:09] PA: Relief post usage of Carbimazole
[29-08-2025 08:14] PA: 1. Not feeling exhausted
2. No sweating
3. Pain in stomach reduced to almost 70-80%
4. Wait gained from 50(06/08/2025) to 52kg (26/08/2025)
5. Stool frequency has decreased from 3-4 times a day to 1-2 times a day, rarely 3 times
6. Reduced joint pains
7. Thickening of Hair
8. Eyes balls that don't pop out
9. Heartbeat decreased (Patient could notice his heart racing before using carbimazole, he could see it through and hear it when he plugs in earphones)
10. No palpitations if he does a bit of jogging
[29-08-2025 08:16] PA: Things that still need to be changed
1. Still couldn't sleep before 1:30 or 2:30 and wake up by 5:30 or 6 (but the quality of sleep has increased as in he doesn't get up in his sleep as much as he used to)
[29-08-2025 08:19] PA: Noticed side effects of Carbimazole (Not sure if it's because of Carbimazole but it did occur during the usage)
1. Sensitivity to sunlight - Patient got mildly itchy whenever he steps out or if there's a change in the environment
2. The whole body got unbearably itchy only one for day 4 days back (22/08/2025) (he took an avil and the itchiness went never returned in these 4days)
[29-08-2025 10:13] PPM 1: Very well described 👏👏
Your patient is lucky to have you as an advocate and I suppose he too is sharing his symptoms meticulously with you👍
[29-08-2025 10:13] PPM 1: @CR let's collate everything into a case report so that the shared information can be analysed further here using Web 2.0-3.0 approaches
[29-08-2025 10:15] PPM 1: This report may have another page where it mentions the total leucocyte count.
Please share the thyroid function test report of T3, T4 , TSH
[29-08-2025 10:17] PPM 1: While you have shared your patient's events very well, please go through our official template here
to see if you can add more.
[29-08-2025 11:00] PA: Sure. T3, T4 TSH Values before Carbimazole
CBC Before Carbimazole
[29-08-2025 11:08] PPM 1: The total leucocyte count is same in both reports
[29-08-2025 19:49] PA: Hi Doctor
Can I start going to the gym again?
[29-08-2025 20:55] PPM 1: Yes if your patient wants to start exercising again please keep sharing his hourly routine including his diet plates here
Check out how this is done by our other patients here 👇
[30-08-2025 01:18] PA: Sure Will do
[03-09-2025 23:03] PA: Day 1 - 3rd Sept 2025
5:30 AM - Woke up
6:15-7:15 - Work out
8:00 - Breakfast
9:00 AM - 1:00 PM- Office
1:00 PM -2:00PM Lunch
2:00 PM -6:00PM Office
6:00 PM -8:30PM Leisure
8:30PM - Dinner
9:15 PM-10:30PM - Office work
10:30 - 11:00 Listened to Music
[03-09-2025 23:05] PA: Breakfast
4 Boiled Eggs (With Ghee and Red Chilli powder sprinkle)
1 Banana
Lunch - Potato and Dal curries Rice and curd
Dinner - Chicken Curry and Rice
PPM 1: 👍
[05-09-2025 08:11] PA: Day 2 - 4th Sept 2025
5:30 AM - Woke up
6:15-7:15 - Work out
8:00 - Breakfast
9:00 AM - 1:00 PM- Office
1:00 PM -2:00PM Lunch
2:00 PM -6:00PM Office
6:00 PM -7:30 leisure
Slept By 8PM
Woke up in btn at 2, slept and Woke up again at 5:30
[05-09-2025 08:12] PA: Breakfast
4 Boiled Eggs (With Ghee and Red Chilli powder sprinkle)
3 Idly
Lunch - 3 Roti, Dal, Bhindi Curry, Carrot Beetroot fry and curd
Dinner - Chicken Curry and Rice
[05-09-2025 08:12] PA: Couldn't Send yesterday as I was asleep by 8
[-5-09-2025 21.09] PA: Day 3 - 5th Sept 2025
5:40 AM - Woke up
6:25-7:25- Work out
8:00 - Breakfast
9:00 AM - 1:00 PM- Office
1:00 PM -2:00PM Lunch
2:00 PM -6:00PM Office
6:00 PM -7:30 Meeting
7:30-9:00 cooked and had food.
Trying to sleep by 9:30
Breakfast - 4 Boiled Eggs (With Ghee and Red Chilli powder sprinkle)
1 Banana and an orange
Lunch - Brown rice, Drumstick tomato curry, Sambar
Dinner - Rice and Aloo curry
[06-09-2025 23:00] PA: Day 4 - 6th Sept 2025
10:00 AM - Woke up
10:20 - Breakfast
11:00-02:00 Attended a Session
2:00 PM Lunch
2:45 PM to 3:30 PM Laundry
04:00 PM to 06:00 PM - Went out
06:00 PM to 08:00 PM slept
08:00PM Had Dinner
9:30 PM Scrolled for a while
11:00PM - Trying to sleep
Breakfast - 4 Boiled Eggs (With Ghee and Red Chilli powder sprinkle)
Smoothie -1 Banana, 50gm Oats, 15gm Peanut butter
Lunch - Chicken Curry rice and Curd
Dinner - Chicken Curry and Rice
[07-09-2025 09:39] PPM 1: One egg per day is a better idea. Please share the food plate images of the patient for us to evaluate better.
[07-09-2025 12.50] PA: Noted Doctor
[07-09-2025 12:52] PA: This is what patient generally use to track and make his own meals
[07-09-2025 12:53] PA: Suggest changes if required
[07-09-2025 12:54] PA: This is made by the patient himself and has been using it for the last 4 years excluding Jan to July end 2025
[07-09-2025 12.56] PPM 1: 👆@PPM3@PPM2 @PPM5@PPM6 please check out the nicely done work of this patient's advocate here as far as quantitative documentation of his diet energy inputs are concerned
[07-09-2025 16:19] PPM 2: Fantastic work! Would love to see pictures of food plates though.
[07-09-2025 16:20] PPM 2: Hopefully one day our sensor will be able to pick how much salt the foodplate has and how many micro nutrients etc.
[07-09-2025 17:23] PA: Will share starting tomorrow morning
[07-09-2025 18:33] PPM 5: Brilliant!!
[07-09-2025 18:33] PPM 5: What is the patient advocate using to compute this from the patient's food plate? Any app?
[07-09-2025 19:05] PA: The patient weighs the ingredients before cooking so that it is easier to track macro nutrients. Nutrition facts of each ingredient are gathered from either food labels or through a Google search,
Once obtained
According to patients knowledge Each Carb and Protein is multiplied by 4 as 1gm of carb / protein = 4 calories
And Fat is multiplied by 9 as 1gm fat = 9 calories
[07-09-2025 19:08] PPM 5: Superb! What a patient we have!!
[07-09-2025 19:14] PPM 2: Great work and insights.
[07-09-2025 19:14] PPM 2: I'm curious, why is the patient meticulously tracking these?
[07-09-2025 19:18] PA: Patient is
1. Focused towards long-term health
2. Does workouts (started in 2020 Age 17)
3. Also into Martial Arts So important to maintain weight while getting stronger
[07-09-2025 20:21] PPM 2: Excellent. We should consider changing the title of this PaJR group then.
[07-09-2025 20:27] PPM 1: Suggest a new title!
[07-09-2025 20:50] PPM2: 22/M Health Journey with Graves' Disease
[07-09-2025 21:32] PPM 1: Duration of disease would be useful upfront in the title
[08-09-2025 07.51] PA: Patient converts ingredients in the plate, into a shake using water only, and consume it after Having eggs
[08-09-2025 07:58] PPM 1: I should have taken a side profile of the patient when met him at the time with weight loss etc because now I'm sure that if I see him again he'll look more like a body builder!
[08-09-2025 08:01] PA: Patient has pictures/videos of before the weightloss and after the weightloss
[08-09-2025 08:03] PPM 1: Here are some transformative images of another past patient from may to November 2023. Will try to gather recent ones to update there 👇
[08-09-2025 08:03] PPM 1: Please share in the lateral view as demonstrated above after deidentification.
[08-09-2025 08:03] PA: Sure
[08-09-2025 15:45] PPM 1: Mango?
[08-09-2025 16:38] PA: Yes
[08-09-2025 23:46] PA Day 6- 8th Sept 2025
5:30 AM - Woke up
06:00 AM to 07:00PM workout
08:00 AM - Breakfast
09:00 AM to 1:30 PM Office
1:30 PM Lunch
2:00 PM to 6:30PM office
08:00 Rested
08:30 to 9:30PM office related work
9:30 PM Dinner
12:00PM - Trying to sleep
[09-09-2025 07:51] PA: Couldn't find picture references as required
[09-09-2025 07:51] PA: But could get something closer for a rough estimation
[09-09-2025 07:55] PPM 1 @CR we can archive all these very well done image timeline
[09-09-2025 22:28] PA: Day 7- 9th Sept 2025
5:30 AM - Woke up
06:00 AM to 07:00PM workout
08:00 AM - Breakfast
09:00 AM to 1:30 PM Office
1:30 PM Lunch
2:00 PM to 6:30PM office
08:00 Rested
08:30 Dinner
11:00PM - Trying to sleep
[10-09-2025 06:22] PPM 1: 👆What time could the patient sleep on 8th?
[10-09-2025 06:23] PPM 1: Canteen?
[10-09-2025 06:24] PPM 1: 👆 Approximately how much time from 11:00PM may have the patient taken to fall asleep? Half an hour or an hour?
[10-09-2025 06:41] PA: Slept before 10:40
[10-09-2025 06:41] PA: +/- 5 minutes 12:00
[10-09-2025 06:51] PPM 1: The patient mentioned trying to sleep at 11:00 PM
[10-09-2025 06:53] PA: It's a typo trying to sleep "by" 11:00
[10-09-2025 09:25] PA: Dal and Salad is from Canteen, Rest prepared by patient
[10-09-2025 09:27] PPM 1: Patient often uses a canteen kind of plate design during lunch?
[10-09-2025 09:28] PA: No, only when there's a time constraint
[11-09-2025 22:35] PA: Day 8- 10th Sept 2025
5:30 AM - Woke up
06:00 AM to 07:00PM workout
08:00 AM - Breakfast
09:00 AM to 1:30 PM Office
1:30 PM Lunch
2:00 PM to 6:30PM office
08:00 Rested
08:30 Dinner
Slept by 9:15
Breakfast and Dinner Remained same while Lunch was Rice, 1 Roti, Dal and Curd
[11-09-2025 22:39] PA: Day 9- 11th Sept 2025
5:30 AM - Woke up
06:10 AM to 07:10PM workout
08:00 AM - Breakfast
09:00 AM to 1:30 PM Office
1:30 PM Lunch
2:00 PM to 10:15 PM office
Snacks at 6:30- Sunny side up (only one egg - no other ingredients)
9:15PM - Dinner
Trying to sleep by 11:00 PM
As Usual Breakfast and Dinner -for Lunch zeera rice, Sweet Corn, Sambar and Curd
[11-09-2025 22:40] PPM 1: 👍
[12-09-2025 22:26] PA: Day 10- 12th Sept 2025
5:30 AM - Woke up
06:10 AM to 07:10PM workout
08:00 AM - Breakfast
09:00 AM to 11:00 AM office
11:30 Had early lunch from outside
2:00 PM Flight to Mohali
5 PM reached Mohali and the stay
6:30 PM - 9:30 PM Client work
9:30PM Dinner - From outside
10:15 PM - Back to the Hotel
Will try to sleep by 11:00
Snacks at 6:30- Sunny side up (only one egg - no other ingredients)
9:15PM - Dinner
Trying to sleep by 11:00 PM
As Usual Breakfast and Dinner -for Lunch zeera rice, Sweet Corn, Sambar and Curd
[12-09-2025 22:31] PA: Today is also a month on Carbimazole
[12-09-2025 22:31] PA: 32 days to be precise
[12-09-2025 22:43] PA: 1. Quality of sleep has increased a bit more
2. In the past few days patient hasn't slept after 12:00 at night, which in case before patient was (from the past few months to 1-1.5 weeks on Carbimazole) unable to sleep till 1:30 or 2:30
3. Increased energy levels
4. 0 to no Sweating observed even during workouts
5. No pulsating in stomach at all
6. No joint pains - but there's a sense of discomfort while doing squats
7. No Palpitations while resting or standing or walking or jogging, they only come if patient push past my limits and go away in 10-15 secs of rest
8. No Headaches
[12-09-2025 22:57] PA: Stool frequency remained at 1-2 times a day
A bit anxious at times
Tremors
[12-09-2025 23:02] PA: No sensitivity to sunlight observed during the last 10 days
Nor any amount of itchiness
[13-09-2025 07:12] PPM 1: I guess it would still be prudent to get his hemogram checked monthly as carbimazole can be notorious in reducing the neutrophil count.
Check out one of our other patients of Grave's disease hemogram trends here: https://pajrcasereporter.blogspot.com/2025/03/32f-pregnancy-associated-graves-disease.html?m=1
[13-09-2025 08:03] PA: Got it, will do as said.
[13-09-2025 18:59] PA: Hemogram as of 13th Sept 2025 - 33 days on Carbimazole
[13-09-2025 19:00] PPM 1: Looks good
[16-09-2025 22:10] PA: Day 11 13th Sept 2025
03:50 AM – Wake up, wash
04:00 – 06:30 AM – Deep work (urgent reports, presentations)
06:30 – 07:00 AM – Shower + quick breakfast
07:00 – 09:30 AM – Emails + prep for meetings
09:30 – 12:30 PM – Back-to-back office calls/meetings
12:30 – 12:40 PM – Lunch
01:00 – 06:00 PM – Project work + client deliverables + team sync
06:00 – 09:00 PM – Finalize documents, follow-ups
09:00 – 09:30 PM – Dinner
09:30 – 12:30 AM – Extra office work (catch-up, strategy)
12:30 – 03:50 AM - sleep
Day 12 - 14th sept 2025
04:00 AM – Wake up
4:30 – 07:00 AM – Focused deep work (analysis, reports)
07:00 – 07:30 AM – Shower + breakfast
07:30 – 10:30 AM – Calls + client discussions
10:30 – 01:00 PM – Team reviews + urgent emails
01:00 – 01:30 PM – Lunch
01:30 – 07:00 PM – Non-stop project execution (presentations, Excel, docs)
07:00 – 07:30 PM – Dinner
07:30 – 11:30 PM – Work on delayed tasks / strategy work
11:30 – 01:15 AM – Review reports, plan next day
01:25 – 04:15 AM - sleep
Day 13 (15th Sept 2025)
04:30 AM – Wake up
04:45 – 06:30 AM – Prepare decks, write emails, urgent deliverables
06:30 – 07:00 AM – Shower + quick bite
07:00 – 11:00 AM – Marathon meetings (client & internal)
11:00 – 12:30 PM – Documentation + follow-up tasks
12:30 – 01:00 PM – Lunch
01:00 – 07:00 PM – Project execution (tight deadlines + syncs)
07:00 – 07:30 PM – Dinner
07:30 – 11:00 PM – Office backlog clearing + emails
11:00 – 03:30 AM - sleep
[16-09-2025 22:17] PA: Day 14 (16th sept 2025)
03:30 AM – Wake up, get ready
04:00 – 05:20 AM – Client meeting (early start)
05:40 – 07:30 AM – Travel to airport, quick breakfast on the go
07:30 – 09:30 AM – Flight to Hyderabad
09:30 – 10:30 AM – Commute from airport + quick catch-up calls
10:30 – 01:00 PM – Client meetings in Hyderabad (presentations, discussions)
01:00 – 01:30 PM – Working lunch with team/client
01:30 – 05:30 PM – Project execution + follow-up tasks
05:30 – 07:00 PM – Team sync / additional client touchpoints
07:00 – 07:30 PM –Dinner
07:30 – 10:30 PM Liesure
Will try to sleep by 11
Lunch - Day 11. Chole bhature Day 12. Dal chawal Day 13. Chicken burrito bowl
Day 14. Veg Pulao with Raita (couldn't take reference pictures)
Dinner - Chicken Ketsu with rice - Dinner for all 4 days
[17-09-2025 22:15] PA: Day 15 (17th sept 2025)
06:30 AM – Wake up, get ready
09:00 – 01:30 PM – office
1:30 - PM Lunch
2:00 PM to 6:30 PM office
08:00 PM - Dinner
08:30 – 10:30 PM Liesure
Will try to sleep by 11
[17-09-2025 22:16] PA: Breakfast remained same. Lunch entirely from the canteen.
[18-09-2025 08:01] PPM 1: 👍👍
5:30 AM - Woke up
06:00 AM to 07:00PM workout
08:00 AM - Breakfast
09:00 AM to 1:30 PM Office
1:30 PM Lunch
2:00 PM to 6:30PM office
08:00 Rested
08:30 to 9:30PM office related work
9:30 PM Dinner
Trying to sleep by 11:15PM
Breakfast and Dinner as usual
Lunch - Tamarind Rice with dal
[11.01 pm, 31/12/2025] PA: Sorry for not being in touch. The patient met with an accident and couldn’t connect during this period. Medications and the same diet were continued. Recovered about a month ago, but follow-up got delayed due to work and hesitation of not being touch for all these days . Requesting your support sharing blood test reports dated 29th Dec 2025.
[11:09 pm, 31/12/2025] PPM 1: The thyroid tests look good 👏
The other tests look fine too except a few that were perhaps not necessary.
What medication is the patient currently on?
[11:19 pm, 31/12/2025] PA: Carbimazole 10mg
[11:40 pm, 31/12/2025] PPM 1: Once only?
[12:04 am, 01/01/2026] PA: Only carbimazole 3/Day
[7:53 am, 01/01/2026] PPM 1: Oh so 30 mg per day?
[7:54 am, 01/01/2026] PA: Yes
[8:20 am, 01/01/2026] PPM 1: 👆The 30 mg of carbimazole appears to be having a salutary effect on this patient's thyroid function as of December 29, 2025👍
[8:35 am, 01/01/2026] PA: Noted. Should the same dose be continued?
[8:39 am, 01/01/2026] PPM 1: Yes and rechecked again in three months along with hemogram and regular weekly monitoring and sharing of weight and other symptoms
[1:16 pm, 01/01/2026] PA: Noted will do
[6:52 pm, 07/01/2026] PA: Weight as on 07/01/26 - 63.4 Kgs
Weight as on 06/08/25 - 50kgs (Approx 49 Kgs Before Starting Carbimazole)
As per the patients observation most of the issues are recovered and regained. (except for the volume and thickness of Hair)
Observed Palpitations only once on 3rd Jan in a period of 3 months
[6:59 pm, 07/01/2026] PPM 1: Thanks for the update
[12.01 am, 16/01/2026] PA: Weight as on 15/01/2026 - 63.2 kg
[8.59 pm, 21/01/2026] PA: Weight as on 21st Jan 2026 - 64.2 kg[11:16 pm, 21/01/2026] PPM 2: I would recommend the dose be lowered to 15mg.
Did the patient test positive for TSH receptor antibodies?
[11:17 pm, 21/01/2026] PPM 2: @PaJR Health can you find this 22M graves disease patient record from our database?
[11:16 pm, 21/01/2026] PPM 2: @PA
[11:17 pm, 21/01/2026] PaJR Health: I found the following PaJR Record for a 22M Graves Disease patient:
*PAJR RECORDS*
📍 22M Graves Disease recent diagnosis on carbimazole Telangana PaJR - http://pajrcasereporter.blogspot.com/2025/08/22m-graves-disease-recent-diagnosis-on.html
[11:18 pm, 21/01/2026] PPM 2: Excellent. Can you perform an in depth analysis of his record and present his serial TFTs and his Carbimazole dose
[11:18 pm, 21/01/2026] PaJR Health: *PATIENT RECORD ANALYSIS: 22M GRAVES DISEASE*
Here is an in-depth analysis of the patient's record, focusing on serial Thyroid Function Tests (TFTs) and Carbimazole dosage.
*CARBIMAZOLE DOSAGE*
💡 The patient was initially on *Carbimazole 10mg*.
💡 As of December 31, 2025, the patient was taking *Carbimazole 10mg, three times a day, totaling 30mg per day.*
💡 The current recommendation is to *continue the 30mg daily dose* and recheck in three months.
*SERIAL THYROID FUNCTION TESTS (TFTs)*
*TFTs Before Carbimazole (Date not explicitly stated, but before 18-08-2025)*
💡 *T3:* 2.56 ng/mL (Reference Range: 0.60 - 1.81 ng/mL) - *High*
💡 *T4:* 17.0 ug/dL (Reference Range: 4.5 - 12.0 ug/dL) - *High*
💡 *TSH:* <0.005 uIU/mL (Reference Range: 0.35 - 5.50 uIU/mL) - *Low*
*TFTs on December 29, 2025 (After ~4 months on Carbimazole)*
💡 *T3:* 1.23 ng/mL (Reference Range: 0.60 - 1.81 ng/mL) - *Within normal range*
💡 *T4:* 7.8 ug/dL (Reference Range: 4.5 - 12.0 ug/dL) - *Within normal range*
💡 *TSH:* 2.14 uIU/mL (Reference Range: 0.35 - 5.50 uIU/mL) - *Within normal range*
*SUMMARY OF TFT TRENDS*
💡 The patient's TFTs show a significant improvement from hyperthyroid levels before Carbimazole treatment to within the normal reference ranges by December 29, 2025, indicating a positive response to the medication.
*REFERENCE*
📍 22M Graves Disease recent diagnosis on carbimazole Telangana PaJR - http://pajrcasereporter.blogspot.com/2025/08/22m-graves-disease-recent-diagnosis-on.html
[11:20 pm, 21/01/2026] PPM 2: Right. Can you review his record and tell us if he tested positive for TSH-R antibodies?
[11:20 pm, 21/01/2026] PaJR Health: I have reviewed the patient's record, and there is no mention of TSH-R antibody testing or its results in the provided information. The record includes serial TFTs (T3, T4, TSH) and hemogram results, but not TSH-R antibodies.
[5:49 am, 22/01/2026] PA: No TSH-R test hasn't been done yet,
Should I get back with the referred test?
[1:47 pm, 22/01/2026] PPM 2: I would suggest so. Antibody negative Graves recurs less often than antibody positive graves. Dose reduction is the only way we will know if your graves has gone into remission. Hence would suggest dose to be reduced to 15mg.
[1:53 pm, 22/01/2026] PA: Noted, Will Follow
[9.07 am, 26/01/2026] PA: Results of TSH receptors
[1:06 pm, 26/01/2026] PPM 2: Right. This is relevant for risk of recurrence and possible eye disease. Was it ever mentioned to you or did you at point have eye symptoms?
[1:07 pm, 26/01/2026] PA: No, Not any eye symptoms
[1:13 pm, 26/01/2026] PPM 2: Alright. Has the patient decreased his Carbimazole to 15mg?
[1:13 pm, 26/01/2026] PA: Yes, from the last recommended day
[1:15 pm, 26/01/2026] PPM 2: Alright. Please get a repeat TFT in 2 months
[1:15 pm, 26/01/2026] PA: Sure
[1:16 pm, 26/01/2026] PA: Should the 15mg be continued for the next two months ?
[1:18 pm, 26/01/2026] PPM 2: Yes.
[1:18 pm, 26/01/2026] PA: Noted
[1:18 pm, 26/01/2026] PPM 2: Also would recommend an LFT (liver function test) at the next blood test.
[1:18 pm, 26/01/2026] PA: Sure
[2.22 pm, 26/01/2026] PPM 1: 👍
[6:25 pm, 26/01/2026] PPM 2: @PaJR Health find the record for this 22M graves
[6:25 pm, 26/01/2026] PaJR Health: I found the following PaJR Record for a 22M Graves Disease patient:
*PAJR RECORDS*
📍 22M Graves Disease recent diagnosis on carbimazole Telangana PaJR - http://pajrcasereporter.blogspot.com/2025/08/22m-graves-disease-recent-diagnosis-on.html
[6:25 pm, 26/01/2026] PPM 2: Excellent. Did this patient ever get an US Thyroid
[6:25 pm, 26/01/2026] PaJR Health: I have reviewed the patient's record, and there is no mention of an Ultrasound Thyroid being performed or its results in the provided information.
[6:30 pm, 26/01/2026] PPM 1: @PA can you share your patient's deidentified initial OPD ticket where the clinical findings were written as well as report of ultrasound neck if at all done at that time?
[6:58 pm, 26/01/2026] PA: US wasn't done, I'll share the OPD
[9.13 pm, 26/01/2026] PPM 1: To be added as dyadic conversations around this patient: 22M with thyrotoxicosis https://pajrcasereporter.blogspot.com/2025/08/22m-graves-disease-recent-diagnosis-on.html?m=1
[26/01, 20:55]hu3: Good evening sir
Sir I had a query regarding 22M patients diagnosed with Grave's disease.
How do we diagnose antibody negative graves disease and does it have same prognosis as antibody positive grave's?
[26/01, 21:10]hu2: Good question.
Grave's disease gold standard diagnosis appears to be clinical with eye signs and hyperthyroidism
We were just having a discussion around it in pm with our other team members shared below:
[26/01, 14:23]hu2: How does past statistical association with risk change the patient's future as currently the test didn't change our management?
[26/01, 14:42]hu1: Terrific question - how were we sure of Graves in the first place? Did we rule out a functioning nodule sir?
[26/01, 14:43]hu1: The problem is that the commonest cause of Nodules is Graves itself. The TSHR antibody positivity makes Graves likeliest and if any Nodules found, would attribute it to Graves now.
[26/01, 14:43]hu1: All likelihoods not absolutes.
[26/01, 14:56]hu2: Clinical examination with eye signs is the only thing that distinguishes the hyperthyroidism as Graves?
[26/01, 15:04]hu1: If present yes. If not, how? Goitre unfortunately can also be from TMNG or Toxic Adenoma too
[26/01, 17:58]hu2: If no eye signs and no Graves disease, even then how would the management be different between toxic multinodular goitre and toxic adenoma which would be diagnoses of exclusion from Graves? @Meta AI
[26/01, 17:58] Meta AI: Let's break it down.
If it's Toxic Multinodular Goitre (TMNG) or Toxic Adenoma, management's gonna differ from Graves' disease mainly because the underlying cause and pathology are different.
- *TMNG*:
- Radioactive iodine ablation is often preferred, esp. if the goitre's large or there's significant hyperthyroidism.
- Surgery's another option if there's compressive symptoms or if it's a large goitre.
- *Toxic Adenoma*:
- Surgery (lobectomy or nodule removal) is often preferred, esp. if the nodule's benign on FNAC.
- Radioactive iodine ablation's also an option, particularly if surgery's not feasible.
If no eye signs and no Graves' disease, you'd likely go for:
1. Thyroid scan to differentiate between TMNG (patchy uptake) and Toxic Adenoma (solitary hot nodule).
2. Manage hyperthyroidism with antithyroid drugs initially, then consider definitive treatment (surgery/RAI) based on the diagnosis.
Does that help clarify things?
[26/01, 18:00]hu2: @Meta AI epidemiologically would you have data on how many patients of toxic adenoma vs Graves remain on anti thyroid medication alone in India?
[26/01, 18:00] Meta AI: Unfortunately, specific epidemiological data on the number of patients with toxic adenoma vs Graves' disease remaining on anti-thyroid medication alone in India isn't readily available. However, here's some context:
- Graves' disease is the most common cause of hyperthyroidism, accounting for 50-60% of cases, while toxic adenoma accounts for a smaller percentage.¹
- Antithyroid medications are often used as initial treatment for Graves' disease, but the recurrence rate is high (20-70%) after treatment discontinuation.²
- For toxic adenoma, antithyroid medications are typically not considered a long-term solution, and definitive treatments like surgery or radioactive iodine ablation are often recommended.³
To get more accurate data specific to India, I'd suggest looking into studies published in Indian medical journals or databases like PubMed or MedIND.
Would you like me to search for more specific studies or data on this topic? Or are you looking for information on treatment approaches for these conditions?
[26/01, 18:00]hu1: This is the thing isn't it - if he were antibody negative, Carbimazole alone would suffice, but because he is antibody positive, he needs definitive management with RAI or Surgery.
Risk of Future Osteoporosis and AF is higher with antibody positive Graves and subclinical Thyrotoxicosis too.
[26/01, 18:01]hu1: Because risk of relapse is much higher.
[26/01, 18:01]hu1: Carbimazole for more than 12 or at best 18 months is hepatotoxic (not much I've seen in real life though - but again I'm too inexperienced)
[26/01, 18:05]hu1: For autonomous Nodules long term therapy with Surgery or RAI is your go to. Carbimazole can't treat the pathology. And that is the point here - because this is Graves (with the receptor antibody positive now), he can be on Carbimazole only got upto 18 months. However if a nodule, then your strategy would change wouldn't it.
Even if he has a few Nodules now, you can attribute it to Graves instead of taking the Nuclear scan route.
[26/01, 18:17]hu2: Check out PaJR patients on carbimazole for years by typing carbima
azole in the PaJR search box here:
[26/01, 18:21]hu2: We too were text book trained that way but experience showed that most patients didn't bother to get Surgery or RAI ablation done and recovered on tablets alone although again we don't have enough PaJR data yet to be able to claim it reasonably other than being labeled anecdotal
[26/01, 18:24]hu1: I agree. But we could have done a US Thyroid. I will check if it was done.
[26/01, 18:29]hu2: Will need to ask him to share all his deidentified OPD tickets with clinical findings and ultrasound reports as none of those are available in the case report link
[26/01, 18:29]hu1: Yes please. But you see the TSHR antibody is now a diagnostic shortcut and any nodule now found will be attributable to the Graves instead of a TNG in itself.
[26/01, 18:31]hu2: @Meta AI what is the diagnostic sensitivity and specificity of the TSHR antibody in diagnosis of graves
[26/01, 18:31] Meta AI: The TSHR antibody test is a game-changer for diagnosing Graves' disease. The sensitivity and specificity of TSHR antibodies in diagnosing Graves' disease are quite high.
- Sensitivity: around 97-100% for untreated Graves' disease patients
- Specificity: around 95-99%¹ ² ³
Using a TSI index of 1.3 as the cutoff level in newly diagnosed, untreated patients, sensitivity and specificity are higher than 90%. For a higher cutoff of 1.8, specificity approaches 100%, but sensitivity decreases somewhat.
Third-generation assays have even better performance, with sensitivity and specificity of 97.4% and 99.2%, respectively.
Given the high sensitivity and specificity, a positive TSHR antibody test can indeed confirm Graves' disease, making it a valuable diagnostic shortcut.
Do you want to explore how TSHR antibody levels impact treatment decisions or prognosis in Graves' disease? Or would you like more information on interpreting TSHR antibody test results?
[26/01, 18:33]hu1: If they recovered it likely means they were Graves in the first place and not TNG or TMNG
[26/01, 18:33]hu2: @Meta AI can you share one single study of diagnostic sensitivity specificity of TSH receptor antibodies in Graves and share the results in a PICO format taking care not to share relative percentages but just the absolute numbers?
[26/01, 18:33] Meta AI: Here's a study on the diagnostic sensitivity and specificity of TSH receptor antibodies in Graves' disease, presented in PICO format with absolute numbers:
*Study:* Tozzoli et al. (2010) - Accuracy of receptor-based methods for detection of thyrotropin-receptor autoantibodies: a new automated third-generation immunoassay shows higher analytical and clinical sensitivity for the differential diagnosis of hyperthyroidism.¹
*PICO:*
- *P* (Population): 185 patients with Graves' disease, 100 patients with non-Graves' hyperthyroidism, and 100 healthy controls
- *I* (Intervention): Third-generation TSH receptor antibody (TRAb) assay
- *C* (Comparison): Clinical diagnosis of Graves' disease
- *O* (Outcome):
- True positives (TP): 181/185 Graves' disease patients tested positive for TRAb
- False negatives (FN): 4/185 Graves' disease patients tested negative for TRAb
- True negatives (TN): 199/200 non-Graves' hyperthyroidism patients and healthy controls tested negative for TRAb
- False positives (FP): 1/200 non-Graves' hyperthyroidism patients and healthy controls tested positive for TRAb
*Results:*
- Sensitivity: 181/185 (TP/(TP+FN))
- Specificity: 199/200 (TN/(TN+FP))
Would you like me to explore more studies on this topic or provide more information on interpreting TSH receptor antibody test results?
[26/01, 18:35]hu2: Current studies appear to have taken clinical diagnosis of Graves as the gold standard
[26/01, 19:34]hu1: Will need to go through the entire paper
[10:48 am, 27/01/2026] PA: Unfortunately couldn't find OPD.
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