Q: What important differential diagnoses could imaging help identify/exclude? show answer
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Emergency admission with pleuritic chest pain, shortness of breath, cough and leg swelling. Generally unwell over two weeks, with significant weight loss over a few months. No known medical history. Non-smoker. Vacation within the last month with three hour flight. No medications. New fast AF (215 bpm).
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Allowing for AP projection, marked cardiomegaly. Prominance of central pulmonary vessels. Small bi-basal pleural effusions.
This patient presented with chest pain and breathlessness on a background of weight loss and lethargy. Further history revealed a sub-acute history of heat intolerance and fine tremor. There was a family history of over-active thyroid.
The main finding in this patient's blood tests was abnormal thyroid function: free T4 (45), elevated free T3 and thyroid receptor antibodies and fully suppressed TSH.
This biochemical and clinical scenario was consistent with thyroid storm.
There were a number of management steps this patient required in the emergency setting:
When the heart rate was better controlled, a repeat echo confirmed the above findings and the patient underwent DC cardioversion to good effect.
Case contributed by Dr Gilly Fleming
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