This patient is exhibiting signs and symptoms consistent with thyroid storm. Thyroid storm is a rare, life-threatening hypermetabolic state caused by severe thyrotoxicosis. The most common precipitating factor is infection. A well-recognized and important complication of thyroid storm is high output heart failure. This patient is exhibiting signs of thyroid storm, as well as high output heart failure. Signs and symptoms of thyroid storm include anxiety, tremulousness, psychosis, obtundation, seizures, coma, fever, tachycardia (out of proportion to fever), circulatory collapse, diarrhea, and vomiting. Thyroid storm is a clinical diagnosis. Management of thyroid storm includes supportive therapy with airway protection, intravenous fluids, cardiac monitoring, and supplemental oxygen. Fever may be treated with acetaminophen as salicylates have the potential to increase T4 and T3 levels. Adrenergic blockade is the most important initial component of therapy. Propranolol, a nonspecific b-blocker, is used to decrease sympathetic hyperactivity and partially block peripheral conversion of T4 to T3. Antithyroid drugs should then be initiated. Propylthiouracil and methimazole are both options as both block the synthesis of thyroid hormone; however, propylthiouracil has the added benefit of decreasing conversion of T4 to T3 and works faster than methimazole. One hour after antithyroid drug administration, iodide should be given to inhibit the release of stored thyroid hormone. Steroids also serve as an adjunct to decrease peripheral conversion of T4 to T3.
a) Cardiac tamponade (A) is more classically associated with rheumatologic diseases such as rheumatoid arthritis or systemic lupus erythematosus and presents with obstructive shock due to right ventricular collapse. Pulmonary embolism (C) also presents with acute obstructive right heart failure as opposed to high output heart failure. Tension pneumothorax (D) also presents with an obstructive shock picture as venous return to the right heart is severely impaired.
A 30-year-old man presents to the emergency department with an ankle injury after he twisted his ankle when stepping off of the curb. The patient mainly complains of pain near the right lateral malleolus. Which of the following examination findings would be more indicative of an ankle sprain that would not require further diagnostic imaging?
a) Bony tenderness in the malleolar zone
b) Bony tenderness in the midfoot zone
c) Inability to bear weight on the ankle
d) Swelling over the bilateral malleoli
