https://clinicalproblemsolving.com/wp-content/uploads/2017/05/HDX_BMCBrigham_Sharmin_FINAL-2.mp3

Dr. Leela Chockalingam presents a Human Dx unknown to Sharmin and BMC resident – Dr. Amir Gilad and Brigham resident  – Dr. Hannah Chen.

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Human Dx case

Abdominal pain schema

Dyspnea schema

Altered mental status schema

Amir Gilad

Amir Gilad is a PGY-1 (very soon to be PGY-2!) at Boston Medical Center. Born and raised in Toronto, he attended Boston University for medical school and loved it so much that he stayed on for his internal medicine residency. He’s an aspiring cardiologist who is passionate about medical education. Outside of medicine he enjoys cheering on his beloved Toronto sport teams, jogging along the Charles River, and exploring the beautiful city of Boston. 

Hannah Chen

Hannah Chen is a second year internal medicine resident at the Brigham & Women’s Hospital. She graduated from the University of North Carolina School of Medicine.  She has an interest in hospital medicine, nephrology, and health equity.  In her spare time, she enjoys eating/cooking and hiking.  

Leela Chockalingam

Leela Chockalingam grew up in Rochester, NY. She studied Chemistry at Carnegie Mellon University and then attended medical school at the Icahn School of Medicine at Mount Sinai in New York City. During medical school, she spent a year in Vietnam doing tobacco use treatment research. She is currently an Internal Medicine resident at the University of Colorado in Denver, CO. She is interested in pursuing pulmonary critical care fellowship, and would ultimately love to be a clinician educator focused on clinical reasoning and evidence based medicine. Her hobbies include reading fiction, being outside, and cooking for family and friends. 

Case recap

A 47-year-old man with alcohol and meth use presented with acute dyspnea, abdominal pain, and encephalopathy, and was found to be in acute congestive heart failure with atrial fibrillation and rapid ventricular rate. While in the emergency department, his oxygen requirement rapidly increased and he required intubation for hypoxemia and airway protection. Further evaluation revealed a suppressed thyroid stimulating hormone with an elevated free T3 and free T4, confirming a diagnosis of thyrotoxicosis meeting criteria for thyroid storm.

Teaching points

Hyperthyroidism refers to increased synthesis and release of thyroid hormones from the thyroid gland, whereas the term “thyrotoxicosis” represents the clinical syndrome produced by excess circulating thyroid hormone. The most common causes of hyperthyroidism include Grave’s disease, toxic nodular goiter/adenoma, and drug induced thyroid dysfunction. Thyrotoxic states can also occur when thyroid hormones are released from an injured thyroid gland in thyroiditis (autoimmune, viral, suppurative) or ingestion of exogenous thyroid hormone.

The clinical manifestations of hyperthyroidism can result from the thyrotoxic state itself (e.g., palpitations, fatigue, tremor, weight loss) or be related to the underlying cause of hyperthyroidism (e.g., grave’s ophthalmopathy, globus sensation/dysphagia from enlarged goiter). Complications of thyrotoxicosis include atrial fibrillation (with possible heart failure), thyrotoxic periodic paralysis, osteoporosis, and reproductive issues. Thyroid storm represents life-threatening thyrotoxicosis and its diagnosis is supported by the Burch & Wartofsky Score, which takes into account temperature, central nervous system effects, gastrointestinal/hepatic dysfunction, cardiovascular dysfunction, and the presence/absence of a precipitating trigger.