It’s Stormy

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    It’s Stormy

    28 you F with no known PMH, p/w palpitations x 3 days after bus trip to Washington DC, states she is feeling “awful”, symptoms have been constant and worsened today.  Also endorses b/l LE swelling, nausea, vomiting x1 per day, fatigue, diaphoresis, mild SOB.  Notes generalized yellowing of skin.  Denies CP, no fevers, no cough.  No sick contacts, no travel outside of the country.

    Endorses occasional etoh abuse, no tobacco, no other drug use

     

    Exam:

    VS: 96.6, 147, 156/56, 22, 100% RA

    Gen: anxious, diaphoretic, jaundice

    HEENT: +scleral icterus, mmm

    CVS: irregularly irregular, tachycardic, no m/r/g

    Resp: CTAB

    Abd: soft, NTND, no appreciable hepatomegaly

    Ext: 2+ pitting edema b/l

    Neuro: A/Ox3, nonfocal

     

    EKG: rapid afib

     

    Notable labs:

    Platelets 26

    PT/PTT/INR 30/66/2.6

    Tbili/Dbili 13.5/5.5

    AST/ALT/AlkP 137/51/208

    GGT/LDH 26/446

    Lactate 4.5

    Negative urine pregnancy

    CXR: cardiomegaly

    Biggest concern?

    THYROID STORM

    Burch and Wartofsky’s diagnostic criteria for thyroid storm:
    Thermoregulatory dysfunction
    Temperature (°F | °C)
    99 to 99.9 | 37.2 to 37.7 5
    100 to 100.9 | 37.8 to 38.2 10
    101 to 101.9 | 38.3 to 38.8 15
    102 to 102.9 | 38.9 to 39.4 20
    103 to 103.9 | 39.4 to 39.9 25
    ≥104.0 | >40.0 30
    Central nervous system effects
    Mild 10
    Agitation
    Moderate 20
    Delirium
    Psychosis
    Extreme lethargy
    Severe 30
    Seizure
    Coma
    Gastrointestinal-hepatic dysfunction
    Moderate 10
    Diarrhea
    Nausea/vomiting
    Abdominal pain
    Severe 20
    Unexplained jaundice
    Cardiovascular dysfunction
    Tachycardia
    99 to 109 5
    110 to 119 10
    120 to 129 15
    130 to 139 20
    ≥140 25
    Atrial fibrillation 10
    Heart failure
    Mild 5
    Pedal edema
    Moderate 10
    Bibasilar rales
    Severe 15
    Pulmonary edema
    Precipitant history
    Negative 0
    Positive 10

    A score of 45 or more is highly suggestive of thyroid storm; a score of 25 to 44 supports the diagnosis; and a score below 25 makes thyroid storm unlikely.

     

    This patient has a score of 80, in patients with probable thyroid storm, which is a clinical diagnosis, you should go ahead and treat without confirmatory studies because mortality from this disease is very high (at least 30% with some sources asserting that delay of treatment may increase mortality to 75%)

     

    Treatment:

    1. Beta blockers (Propranalol), treats symptoms

    2. Methimazole or PTU, block synthesis of thyroid hormone

    3. Iodine, blocks release of thyroid hormone, this must be given after a synthesis blocking agent!!!

    4. Steroids, block conversion of T4 to T3

     

    References:

    Dr. Zara Mathews

    http://www.uptodate.com/contents/thyroid-storm?source=machineLearning&search=thyroid+storm&selectedTitle=1~94&sectionRank=2&anchor=H13827326#H

    S. Karger and D. Führer, “Thyroid storm—thyrotoxic crisis: an update,” Deutsche Medizinische Wochenschrift, vol. 133, no. 10, pp. 479–484, 2008. 

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