Case (59)

[Muna1]

A 37-year-old woman has been brought to A&E with a 1-day history of abdominal pain, diarrhoea and vomiting. She has a history of type-1 diabetes mellitus and pernicious anaemia.
Her partner tells you that her GP has recently prescribed amoxicillin for her chest infection and that she has lost 12.5 kg (nearly 2 stone) in weight over the last few months.
She does not smoke or drink alcohol. On examination, she is flushed, disorientated, agitated and jaundiced. Her temperature is 42.1 °C, pulse 180 bpm and irregular and BP 180/70 mmHg. You detect a third heartsound, her chest is clear and her abdomen generally tender. Her legs are weak proximally and all reflexes brisk. She has some pitting oedema of her lower limbs.
Blood tests reveal:
                        Na131 mmol/l
                        K 2.8 mmol/l
                        urea 17.6 mmol/l
                        creatine 165 μmol/l
                        Ca 2.82 mmol/l
                        bilirubin64 μ mol/l
                        ALT141 U/l
                        alkaline phosphatase210 U/l
                        glucose26.8 mmol/l
                        WBC17.2 × 109/l
                        neutrophils15.6 × 109/l
                        Hb 10.3 g/dl
                        MCV102.4 fl
                        platelets273 × 109 /l

Results of an ECG show a fast AF.

                  What is the most likely diagnosis?


really i miss this web site

[Muna1]

ايه ياجماعه مافي ولا محاوله 
طيب احاول اخليها اسهل 
الخيارات هي
               1-Atypical pneumonia
                         2-Diabetic ketoacidosis
                         3-Thyroid storm
                        4- Gastroenteritis
                         5-Adverse drug reaction
مستنيه الاجابات ان شاء الله

[Guled1]

answwer is N1  ...am i right?...while you waiting the answer the patient already died!!!!
so now give us the answer with simple explanation not a lecture!
and thank you for sharing with us.

[Muna1]

i will give you another chance  

[Muna1]

the correct answer is Thyroid storm

Her past history of diabetes mellitus and pernicious anaemia  make it more likely that she has a further autoimmune  disorder. The history of weight loss suggests an underlying thyroid disorder, with the thyroid storm being precipitated by her chest infection.
 Thyroid storm is a sudden, life-threatening exacerbation of   thyrotoxicosis. Some series suggest a mortality rate of  between 30 and 75%. Its manifestations are due to the action of excess thyroid hormone. Fever is the most characteristic   feature, with the temperature often rising above 41°C. There   may be evidence of organ damage. The clinical picture is  frequently clouded by a secondary infection such as pneumonia           or a viral infection. Death may be caused by cardiac  arrhythmia, congestive heart failure, hyperthermia or other unidentified factors.
  The diagnosis of thyroid storm is made entirely on clinical  grounds. The results of thyroid function tests will rarely be  available soon enough to make the diagnosis.
   Propylthiouracil followed by a stable iodine preparation (eg   Lugol’s iodine) is usually given. Propanolol, intravenous  fluids, dexamethasone and cooling are also often required.  Finally, one must remember to treat the precipitating cause.

[Mustafa]

A little more explanation to understand fully why the other options were not the right answer.
This patient is only mildly acidotic in the presence of hyperglycaemia. This would go against a diagnosis of diabetic ketoacidosis. Hypertension with hypokalaemia, in contrast to hypotension and hyperkalaemia, goes against significant adrenocortical insufficiency. Her calcium is not high enough to cause a hypercalcaemic crisis. Her past history of autoimmune disease makes it more likely that she has a further autoimmune disorder, rather than phaeochromocyotoma.  the thyroid storm is possibly  precipitated by a chest infection treated with antibiotics. Propranolol, intravenous fluids, steroids and cooling are also often required. Treatment of the precipitating cause is also essential.