The "Perfect Storm"

Jaffar Alfardan, MD; Frank H. Wians, Jr., PhD, MT(ASCP); Robert F. Dons, MD, FACE; Kathleen Wyne, MD, PhD, FACE


Lab Med. 2005;36(11):700-704. 

In This Article


Patient: 60-year-old African-American woman.

Chief Complaint: Exacerbation of tremors, sweating, and palpitations over the past week.

History of Present Illness: This patient presented to the emergency department (ED) with nausea, vomiting, watery diarrhea, sweating, tremor, jitteriness, chills, and palpitations of 1 week duration. The patient reported a 60-pound weight loss during the past 2-year period, chronic thinning of hair, and intermittent palpitations. She reported no shortness of breath, cold or heat intolerance, eye changes, difficulty swallowing, or current use of any medications.

Medical History: The patient reported no history of diabetes, hypertension, or heart disease. A review of her medical record indicated that she had presented 2 years earlier with a diffusely enlarged thyroid gland and was diagnosed with hyperthyroidism. At that time, she was admitted to the hospital and treated with propylthiouracil (PTU), steroids, and beta-blockers, but was subsequently lost to follow up.

Family History: Her father had hyperthyroidism and a daughter has Grave's disease. There was no family history of hypertension, diabetes mellitus, or coronary heart disease.

Physical Examination: The patient was diaphoretic, cachectic, and had icteric sclera. Her vital signs were: temperature, 36.2°C (97.2°F); blood pressure, 160/103 mmHg; pulse (heart rate), 196 beats per minute (bpm); and respiratory rate, 16 breaths per minute. She had a non-tender enlarged thyroid with a right side nodule and bilateral bruit. Cardiac examination revealed a Grade III/IV systolic murmur radiating to the axilla and an elevated jugular venous pressure. A prominent tremor in the extremities was noted.

Principal Laboratory Findings: Table 1 .

Additional Diagnostic Testing: Chest x-ray demonstrated a small bilateral pleural effusion with prominent pulmonary vasculature. An electrocardiogram (ECG) demonstrated atrial fibrillation while an echocardiogram showed decreased right and left ventricular function and a left ventricular ejection fraction (LVEF) of only 15% (normal: >50%). A computed tomography (CT) scan, without contrast, of her head was negative for any evidence of bleeding.