History of Present Illness:
A woman in her mid 40’s with no known PMH is brought by police to the ED for medical clearance for jail due to persistent tachycardia. She has been feeling stressed lately and not sleeping well. She occasionally has chest pain going to her right arm. The pain is not exertional or pleuritic but she does feel out of breath when it comes. She denies stimulant use but does smoke tobacco and occasionally drinks.
Vital Signs & Physical Exam:
Vital signs are normal except for a pulse of 125-130 and a blood pressure in the 120’s-130’s. Pulse ox is normal. Oropharynx is moist and lungs are clear. There is no tachypnea. She has slight tremor.
After Ativan and 2 liters of IV fluids the pulse is essentially unchanged.
Initial Diagnostic Testing:
- EKG: sinus tach with no ST or T wave or axis abnormalities
- Blood: CBC and BMP normal
- Imaging: CXR normal
- D-dimer: elevated, above the YEARS criteria cutoff
- CT chest: shown below
What is the most likely diagnosis?
- A) PE
- B) Thyrotoxicosis
- C) Alcohol withdrawal
- D) Pneumonia
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
<<<<<<<<<<<<<<<<<<<<< ADVERTISEMENT & SPACER >>>>>>>>>>>>>>>>>>>>>
****************************************************************************
THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
Get one of our publications, all designed specifically for Emergency Care Providers:
Emergency Medicine 1-Minute Consult, 5th edition
A-to-Z EM Pharmacopoeia & Antibiotic Guide, NEW 5th edition
8-in-1 Emergency Department Quick Reference, 5th edition
******************************************************************************
***************************************************************************
<<<<<<<<<<<<<<<<<<<<<<<<< END SPACER >>>>>>>>>>>>>>>>>>>>>>>>>
What is the most likely diagnosis?
- A) PE – not seen on CT
- B) Thyrotoxicosis – CORRECT – thyroid is huge on CT scan
- C) Alcohol withdrawal – would usually respond to Ativan
- D) Pneumonia – not seen on CT
1-Minute Consult on this topic: Click HERE and scroll to proper page
CASE CONCLUSION: CT showed thyromegaly. TSH <0.01, T4 >24, free T4 >5, T3 >600
CASE LESSONS: Thyrotoxicosis is not that rare. Always consider when you can’t find another cause of tachycardia.