Download For Examiner Only

For Examiner Only
Case Thyrotoxicosis
Author: Tom Morrissey, MD
Tom Morrissey
Reviewer: Rob Blankenship, MD
Approved: 12/6/05
ORAL CASE SUMMARY
CONTENT AREA
Endocrine Emergencies
SYNOPSIS OF CASE
50 yo white female presents with 3 days of nonspecific viral symptoms (productive cough, chills,
some diarrhea). She becomes weak tired and confused as the infection unmasks hyperthyroidism
and thyrotoxicosis, which progresses to thyroid storm if not recognized and appropriately treated.
SYNOPSIS OF HISTORY
10 days the patient began to have diarrhea / loose stools (no blood or mucous) and weight loss
and has noted a swelling in her throat. She saw her doctor about this a few days ago to have lab
tests run, but they are not back yet. 3 days ago began to have URI symptoms including dry
cough, mild sore throat and chills. The cough began to produce sputum “feeling similar to her
bouts of bronchitis in the past”. By evening she was feeling very run-down and weak. This
morning she was “not acting right” so her husband brought her in to the ED. “She is agitated, short
fused, forgetful and not acting like herself” reports her husband.
SYNOPSIS OF PHYSICAL
Medium-thin white female perturbed about being in the ER but no acute distress.
HR 130 irregular
RR 16
BP 180/70
Temp 97.5
O2 sat 94%
Neuro: Normal except 3+ DTRs and mild tremulousness (both at rest and with intention).
Skin: warm to touch, no rash, no diaphoresis
Head/neck: Hair grey thin and limp, eyes mild proptosis and lid lag, neck with palpable thyroid with
tendernodules , otherwise normal
Cor: hyperdynamic, S1S2, irregularly irregular
Pulmonary: Mild crackles in right base, no work of breathing. Tachypneic with a rate of 16.
Abdomen: Normal
Rectal: Rectal watery brown stool, heme negative.
Genito-urinary: Normal
Extremeties: Paucity of hair, strong otherwise normal
CRITICAL ACTIONS
1)
2)
3)
4)
Recognize thyrotoxicosis / thyroid storm
Start empiric treatment of thyrotoxicosis
Look for and treat eliciting events (infection, drugs, iodine ingestion, etc)
Recognize and treat pneumonia
SCORING GUIDELINES
(Critical Action No.)
Need to give PTU for thyrotoxicosis but after iodine or risk worsening symptoms
FOR EXAMINER ONLY
For Examiner Only
PLAY OF CASE GUIDELINES
(Critical Action No.)
1) Patient presents for mild mental status change with thyrotoxicosis as cause. Physical exam reveals
irregular tachycardia, fever, tender thyroid as clues. If not recognized and addressed early, patient
continues to decompensate: 1) mental status gets worse and patient develops seizures 2) high output heart
failure develops and cardiovascular collapse ensues.
2) Begin empiric treatment of thyrotoxicosis/storm. If condition not recognized and treatment begun
empirically, TSH is only lab clue to return (all other TFTs are delayed).
Acceptable treatment options are
-- beta blocker-preferable propranolol (1mg/min till effect or 10mg total) (guanethedine or reserpine are
alternatives, but may not be readily available to candidate)
-- PTU (90-1200mg po) or methimazole (90-120mg po). (PTU more rapid and inhibits peripheral conversion
of t4 to t3
-- Iodide administration (Na-iodide or K-iodide). Must be given after PTU/methimazole or patient worsens
because of release stimulation.
3) Hunt for inciting events
--Infectious sources (CXR, UA, skin eval)
--Ask about medication changes and compliance, and sources of dietary iodine
--DKA
--Physical or emotional stresses
4) Recognize and treat pneumonia. Pt will complain of cough and chest pain. CXR will reveal RLL PNA.
Evaluation for PE will be negative or indeterminate (she doesn’t have one).
--If PNA not recognized and treated, patient will continue with pulmonary deterioration, hypoxia and need for
intubation. If still not recognized she will progress to septic shock and cardiovascular collapse.
--Treatment for community acquired PNA is acceptable (cephalosporin+macrolide or flouroquinolone is
acceptable).
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1.
Recognize thyrotoxicosis/thyroid storm
This critical action is met by the candidate
Cueing Guideline: tender enlarged thyroid, low TSH. Patient will not improve until
appropriate treatment started. Will progress to worsening storm, seizures, high output heart
failure, cardiovascular collapse.
2.
Empirically treat thyrotoxicosis/thyroid storm
This critical action is met by the candidate
Cueing Guideline: TSH is the only thyroid function test to return until appropriate treatment
is begun.
3.
Search for eliciting cause of decompensation
(infection, drugs, iodine ingestion, etc)
This critical action is met by the candidate
Cueing Guideline: Nurse asks if you want other tests. Consultant asks why she is in thyroid
storm.
4.
Recognize and treat pneumonia
This critical action is met by the candidate
Cueing Guideline: Nurse asks if you want any other medications. Respiratory status
worsens, pt becomes hypoxic and needs intubation of pneumonia not recognized and
treatment begun.
For Examiner Only
History Data Panel
50 year old white female
Onset of Symptoms:
3 days, worsening since yesterday.
Description of Complaint:
10 days the patient began to have diarrhea / loose stools (no blood or mucous) and weight loss
and has noted a swelling in her throat. She saw her doctor about this a few days ago to have lab
tests run, but they are not back yet. 3 days ago began to have URI symptoms including dry
cough, mild sore throat and chills. The cough began to produce sputum “feeling similar to her
bouts of bronchitis in the past”. By evening she was feeling very run-down and weak. This
morning she was “not acting right” so her husband brought her in to the ED. “She is agitated, short
fused, forgetful and not acting like herself” reports her husband.
Past Medical History
Surgical: vaginal hysterectomy
Medical: mild childhood asthma
Injuries: none
Allergies: none
Habits
Smoking: cigatettes ( 1 ppd x 25 years)
Drugs: none
Alcohol: none
Family Medical History
Father: none
Mother: thyroid surgery
Siblings: sister died of breast cancer in her 40s
Social History
Married: 30 years
Children: 2 healthy (29 and 27yo)
Employed: ER nurse
Education: RN
For Examiner Only
Physical Data Panel
Patient: Ima Bitconfused 50 year old female
General Appearance: irritated and nervous, but no respiratory distress
Vital Signs:
BP : 180/70
P : 130 irregular
R : 16
T : 102.9
Head: thin limp grey hair
Eyes: mild proptosis, mild lid-lag
Ears: normal
Mouth: normal
Neck: no JVD, no bruits, palpable thyroid with small tender nodules
Skin: warm to touch, no rash, no diaphoresis
Chest: few crackles heard in right base, otherwise normal
Heart: hyperdynamic PMI, S1S2 audible, tachycardic, irregularly irregular,
Abdomen: normal
Extremities: paucity of hair, otherwise normal
Rectal: watery brown stool, no blood or mucus, heme-occult negative
Pelvic: normal
Neurological: Alert and oriented times 3, but agitated. Mild tremor both at rest and with
intended movement. Normal gait. CN 2-12 intact and symmetric. Normal symmetric motor
exam without pronator drift. Normal sensory exam without extinction. DRTs symmetric and
3+. No dysmetias or past-pointing.
Mental Status: Agitated with short attention span.
For Examiner Only
Lab Data Panel
Stimulus #2 - CBC
Complete Blood Count
WBC 13,000
/mm3
Hgb
11
g/dL
Hct
35
%
Platelets 350,000 /mm3
Differential
Segs
79
%
Bands 3
%
Lymphs 16
%
Monos 1
%
Eos
1
%
Stimulus #3 - Chem-7
Na+ 144
K+
4.5
CO2 35
Cl98
mEq/L
mEq/L
mEq/L
mEq/L
Glucose 100
BUN
15
Creatinine 1.0
mg/dL
mg/dL
mg/dL
Stimulus #4 - Urinalysis
Color
Sp gravity
Glucose
Protein
Ketone
Leuk. Est.
Nitrite
WBC
RBC
Yellow
1.020
neg
neg
neg
neg
neg
0-5
0-5
Stimulus #5 - Arterial Blood Gases
pH
7.32
pCO2
pO2
O2 Sat
28
90
95%
mm Hg
mm Hg
%
Stimulus #6 - TSH undetectable
Stimulus #7 – CXR RLL infiltrate (see below)
Stimulus #8 – EKG a-fib. No ischemic chg. (see
below)
Stimulus #9 -- Full Thyroid Function Tests
(sendout)
VERBAL REPORTS
For Examiner Only
Stimulus Inventory
#1
Emergency Admitting Form
#2
CBC
#3
Chem-7
#4
Urinalysis
#5
Arterial Blood Gases
#6
TSH
#7
CXR
#8
EKG
#9
Thyroid Function Tests
#10
FOR EXAMINER ONLY
Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
: Ima Bitconfused
Age
: 50
Sex
: Female
Method of Transportation : Husband in car
Person giving information : Patient and Husband
Presenting complaint
: Not eating right, recent bronchitis and diarrhea
Background: Pt with Hx of bronchitis. Having typical attack after cold symptoms.
Today became more confused and agitated
Vital Signs:
BP : 180/70
P : 130 irregular
R : 16
T : 100.5.F
Stimulus # 2 - CBC
Case Ima Bitconfused
Complete Blood Count
WBC 13,000
/mm3
Hgb
11
g/dL
Hct
35
%
Platelets 350,000 /mm3
Differential
Segs
79
Bands 3
Lymphs 16
Monos 1
Eos
1
%
%
%
%
%
Stimulus # 3 – Chem - 7
Case Ima Bitconfused
Na+
K+
CO2
Cl-
144
4.5
35
98
Glucose 100
BUN
15
Creatinine 1.0
mEq/L
mEq/L
mEq/L
mEq/L
mg/dL
mg/dL
mg/dL
Stimulus # 4 - Urinalysis
Case Ima Bitconfused
Color
Sp gravity
Glucose
Protein
Ketone
Leuk. Est.
Nitrite
WBC
RBC
Yellow
1.020
neg
neg
neg
neg
neg
0-5
0-5
Stimulus # 5 – Arterial Blood Gases
Case Ima Bitconfused
pH
7.32
pCO2
pO2
O2 Sat
28
mm Hg
90
mm Hg
95% %
Stimulus # 6 - TSH
Case Ima Bitconfused
TSH undetectable
Stimulus # 7 - CXR
Case Ima Bitconfused
Stimulus # 8 - EKG
Case Ima Bitconfused
Stimulus # 9 – Thyroid Function Tests
Case Ima Bitconfused
Labs were sent out
Mock Oral Feedback Form
Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
Recognize thyrotoxicosis / thyroid storm
 and omissions
Start empiric treatment of thyrotoxicosis

Look for and treat eliciting events (infection, drugs, iodine
ingestion, etc)
Recognize and treat pneumonia

