Case Presentation

Maureen Betty Braga

Rufaida Julian
John Christopher Luces
Post Graduate Interns
 CASE OVERVIEW
L.G.
60 years old, Female
Married, Christian
Sta. Cruz, Gov Vicente Duterte, Davao City

CC:
 TRIAGE

ER Normal Value
BP 120/70 90/60 mm/Hg to 120/80 mm/Hg
Temp 38.8 36.5 37.6
Pulse Rate 130 60-100
Respiratory Rate 33 12-18
O2 saturation 97
ESI CATEGORY 2
PRIMARY SURVEY

Airway patent

Dyspneic
Tachypneic O2 via face mask
Basal rales at 10 lpm
O2 sat: 97
PRIMARY SURVEY
ABG
Attach to cardiac monitor
(+) pallor Chest Xray
(-) cyanosis ECG
Start IV: PNSS 1L FD 300 cc now
then 100 cc/hr

GCS 15
E4V5M6
PRIMARY SURVEY

(+) pallor
(+) Dyspnea Attach to cardiac monitor
(+) fever Chest Xray, ABG, ECG, CBG
(+) hematemesis Start IV: PNSS 1L FD 300 cc now then 100 cc/hr
(+) epigastric pain Medications for fever & epigastric pain were given
Labs were requested
SECONDARY SURVEY
No known food and drug allergies

PTU (compliant)

1977: Diagnosed with Hyperthyroidism

1985: Thyroidectomy was done (patient became lost to follow up after)
2001: recurrence of anterior neck mass but no consult was done
1 week PTC: Patient was admitted for 3 days in this institution due to
palpitations and patient was started on PTU
(-) HPN; (-) DM; (-) BA;

Lunch: Fish, pork and a cup of rice(1 PM)

Patient was on her way to the ER when she suddenly lose

consciousness and vomited
 History of Present Illness
Patient is a known case of hyperthyroidism and underwent
thyroidectomy 32 years ago patient became lost to follow up
thereafter

1 mo PTC:
patient started experiencing epigastric pain, heat intolerance,
anorexia, and palpitations no consultation was done during this time
 History of Present Illness
10 days PTC:
epigastric pain started to worsen associated with fever and palpitations thus consult in
this institution
Patient was admitted and was started on PTU maintenance patient was then discharged
after 3

5 days PTC:
Recurrence of epigastric pain associated with on and off fever, heat intolerance, diarrhea,
anorexia, dyspnea and palpitations and melena. These symptoms persisted thus consult

Day of consult:
While the patient was on her way to the hospital patient loss consciousness and vomited
coffee ground vomitus
 Personal History
No trauma
(-) Hypertension
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Cardiac problems
(-) Renal Problems
 Family History
No Family History of:
Stroke
Heart disease
Diabetes mellitus
Tuberculosis
Cancer
Hypertension
Asthma
 Personal/ Social History
Civil Status: Married
Occupation: market vendor
Educational Profile: HS grad
Lifestyle habits:
Non-smoker
Non-alcoholic beverage drinker
No history of substance abuse
 Review of Systems
(+) Nausea
(-) Weight Loss
(-) Bowel Changes
(-) Night Sweats
(-) Chills
 Physical Exam

General Survey:
awake, conscious, coherent, in cardiopulmonary distress,
agitated

Skin and Integument: skin is brown smooth, warm to touch.

(+) pallor, no cyanosis. No rashes and skin lesions noted
 HEENT:
Head: normocephalic, hair dark brown and evenly distributed
Eyes: anicteric sclerae, pale conjuctiva, pupils equally round and
reactive to light and accommodation
Ears: intact pinna, no deformities, able to hearing and respond when
name is called
Nose: pink nasal mucosa, midline septum, no sinus tenderness, no
polyps
Mouth: moist, smooth and pinkish oral mucosa, no ulcers or dental
caries, not inflamed tonsils, no exudates
Neck: no neck vein engorgement, no cervical lymphadenopathies, 6x6
anterior neck mass with modular consistency
 Thorax and lungs
Inspection: symmetrical chest expansion
Palpation: no tenderness nor masses
Percussion: Resonant on all fields
Auscultation: Bibasal Rales
 Heart
Inspection: Dynamic precordium
Palpation: PMI at 5th ICS
Auscultation: tachycardic, regular rhythm
 Abdomen
Inspection: flat, umbilicus midline
Auscultation: normoactive bowel sounds
Palpation: soft, tender on epigastric area
 Direct Rectal Examination
Good sphincteric tome
No rectal vault mass
+ Melena on examining finger
 SALIENT FEATURES
SUBJECTIVE OBJECTIVE
60 years old Vital Signs
Fever T= 38.8 C (febrile)
PR = 130 bpm (Tachycardic)
Palpitations RR = 33 cpm (Tachypneic)
Dyspnea BP = 110/80 mmHg
Melena
Epigastric pain PHYSICAL EXAMINATION
Coffee-ground vomits pale conjunctiva, pallor
Agitated
Loss of consciousness 6x6 anterior neck mass with modular consistency
Hyperthyroidism Dynamic precordium
s/p thyroidectomy Bibasal rales
Nausea Epigastric tenderness
DIFFERENTIAL
DIAGNOSIS
 CARDIOGENIC SHOCK
RULE IN RULE OUT
Fever Hypotension
Difficulty of breathing No Jugular Vein Distention
Tachycardia Absent Cardiac murmurs
Bilateral Crackles
Dynamic Precordium
Agitated (altered mental
status)
 SEPTIC SHOCK
RULE IN RULE OUT

Fever No Hypotension
Difficulty of breathing
Nausea and vomiting
Tachycardia
Agitation
 BPUD
RULE IN RULE OUT

Abdominal Pain Cannot Completely Rule Out

Hematemesis
Melena
Fever
Pallor
 COMMUNITY ACQUIRED PNEUMONIA
RULE IN RULE OUT
Tachypnea No history of productive
Crackles cough
Fever
 THYROID STORM
RULE IN RULE OUT

Fever CANNOT RULE OUT

Palpitations
Dyspnea
Epigastric pain
Loss of consciousness
Hyperthyroidism
s/p thyroidectomy
Nausea
 THYROID STORM
RULE IN RULE OUT

pale conjunctiva, pallor CANNOT RULE OUT

Agitated
6x6 anterior neck mass with modular
consistency
Dynamic precordium
Bibasal rales
Epigastric tenderness
 <25 unlikely to represent thyroid storm
25-44 suggestive of impending thyroid storm
>/= 45 highly suggestive of thyroid storm

Parameter PE Score
Temperature 38.8 15
CNS Agitated 10
GI-hepatic function Abdominal pain 10
Cardiovascular Tachycardia at 130 bpm 15

Congestive Heart Failure Bibasal rales 10

Atrial Fibrillation Absent 0

Total 60

HIGHLY SUGGESTIVE OF THYROID STORM

THYROID STORM
Course in the EM Emergency Room
1/13/ 5:26 PM
GCS 15
Awake, conscious, coherent,
in respiratory distress,
pale conjunctiva,
tachycardia and tachypneic
BP= 120/70 5:26 PM
RR= 30 (tachypneic) CBG, ECG, ABG now
CR= 130 (tachycardic) Standby intubation
Temp= 38.8 Attach to cardiac monitor
O2 sat= 97% O2 via face mask at 10 lpm
CBG= 122 IV: PNSS 1L FD 300 cc now them 100 cc/hr
Paracetamol 300 mg IVTT now
Omeprazole 80 mg IVTT now
6:15 pm:
PTU 15 mg tab x 12 tab now
Propanolol 40 mg/tab 1 tab now
Hydrocortisone 100 mg IVTT now
Start Omperazole 80 mg + 80 cc PNSS to run at 10 cc/hr
Labs:
CBC, platelet, UA, serum Na, serum K, Ca, Mg, BUN,
Crea, APTT, PT, Trop I, CKMB, TSH, FT4, FT3, chest xray
BP: 130/70 7:00 pm: TOS to IM
CR: 100
RR: 22
 ECG

Sinus tachycardia
 ABG

Metabolic alkalosis,
partly compensated

Hyperoxygenation
DISCUSSION
 THYROID GLAND
Thyroid hormone affects all organ systems and is responsible
for increasing metabolic rate, heart rate, and ventricle
contractility, as well as muscle and central nervous system
excitability.
Two major types
Thyroxine - is the major form of thyroid hormone.
Triiodothyronine - more potent
 THYROTOXICOSIS or THYROID STORM
- A life threatening exacerbation of Hyperthyroidism

ADRENERGIC
PRECIPITATING EXCESSIVE
HYPERACTIVITY
CONDITION OR THYROID
EVENT HORMONES
ALTERED PERIPHERAL
RESPONSE
THYROTOXICOSIS or THYROID STORM
THYROTOXICOSIS or THYROID STORM

PRECIPITATING FACTORS
Burch Wartofskys Scoring
Burch Wartofskys Scoring
Burch Wartofskys Scoring
 TREATMENT
RATIONALE: Inhibition of thyroid gland synthesis of new thyroid hormone with a
thionamide should be initiated before iodine therapy to prevent the stimulation of new
thyroid hormone synthesis that can occur if iodine is given too soon.

Treatment aims are as follows:

1. Supportive care
2. Inhibition of new hormone synthesis
3. Inhibition of thyroid hormone release
4. Peripheral -adrenergic receptor blockade
5. Preventing peripheral conversion of thyroxine to triiodothyronine
 SUPPORTIVE CARE
Fluid replacement

Administration for IV fluids with dextrose if blood sugar

is relatively low
 SUPPORTIVE CARE
Fluid replacement

Administration for IV fluids with dextrose if blood sugar

is relatively low
Cholestyramine
Inhibition of new thyroid hormone synthesis
Thionamides

Methimazole Propylthiouracil

It can inhibit conversion of T3 to T4

Dosage:
Longer half life than PTU
600 to 1000mg is given PO as loading dose
Presents in free form in the serum
200 to 250mg every 4 hours as
Dosage:
maintenance dose
40 to 100mg given PO as loading dose
Total daily dose: 1200 to 1500mg/day
20mg every 4 hours as maintenance
dose
120mg/day maximum dose per day
 Inhibition of Hormone Release
Iodine
Thionamide therapy must be instituted FIRST
It blocks the release of prestored hormone
Decreases iodide transport and oxidation in follicular cells
Lugol solution, potassium iodide, ipodate or lithium carbonate
Preventing peripheral conversion of thyroxine to
triiodothyronine
PTU
Propanolol
Glucocorticoids
- hydrocortisone or dexamethasone are essential
in treatment
Improves survival rates
Given for patients with severe thyrotoxicosis in
conjuntion with hypotension
 Beta-adrenergic receptor blockade
Propanolol
Given in slow 1 to 2mg boluses which maybe repeated every 10 to 15 minutes
until the desired effect is achieved
Oral dosage
20 to 120mg per dose or 160 to 320mg/day in divided doses
THANK YOU