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 tachycardia. She has been feeling stressed 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. She denies stimulant use but does smoke 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. After Ativan the pulse is essentially unchanged. No definite tremor.
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: mildly 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
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What is the most likely diagnosis?
- A) PE – not seen on CT
- B) Thyrotoxicosis – CORRECT – thyroid huge on CT scan
- C) Alcohol withdrawal
- 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.