Scenerio 1

[ChrisPAinED]

Hi I am Chris a PA that works in a ED. I am not sure what to put in this forum so I am going to do scenarios if that's okay.

I had a patient a while back that presented with chest tightness, palps, and SOB. Triage vitals were HR 130s BP 130s/70s O2 90% RR 34 temp 98.9f. so after taking a history we find out that has a history of asthma and chronic bronchitis. ECG was sinus tachycardia and CXR showed some air trapping. Breathing sounded a bit wheezing but rapid and shallow. Heart sounded good. Labs showed a high white blood count, slightly elevated troponin, significant elevated TSH, neg drug screen, low potassium, and a elevated CRP. 

So high heart rate and low potassium made me think dehydration. Note: no reported diarrhea. So I did order 500cc normal saline IV. 

Elevated TSH and supervising physician said to prescribe levelthyroxine 25mg so did that. 

Elevated CRP and white blood count so prescribed Azithromycin 250 for 5 days. 

Wheezing and slightly low O2 so a nebulizer was used. O2 came up to 97%

After fluids were done still a high heart rate. So maybe thyroid related. 

So heart rate was increasing with talking and moving. Like was 110 and patient started talking then it was 150 and dropped to 115. 

So I consulted internal medicine because patient still had palps and heart rate was running high. Patient was admitted for IV antibiotics and given a steroid and was discharged 2 days later. 

Thoughts? 

 

 

[LT_Oneal_PAC]

@ChrisPAinED

hey Chris, we love scenarios and helps everyone learn.

Well, if it was the TSH that was high and not the T4 I can tell you it had nothing to do with the thyroid. I assume the T4 was low since your “supervising” physician said to give synthroid. Hypothyroids doesn’t make you tachycardic. I don’t think I would have ordered a TSH at all in this presentation. They have much better reasons for tachycardia than hyperthyroidism.

you say what was deranged but not the actual levels. Potassium of 2.5 is different from 3.4, and WBC 12k is different from 20k. there is also no mention of an ABG that point to a hypercapnic issue and help determine if it was chronic or acute or acute on chronic.

You don’t mention the ROS if they complained of any systemic infectious symptoms, not any patient provided history such as increase productive cough, smoking, home medications. Would also like an age, gender, and weight.

did you just give one neb?

I do think the 500cc bolus was appropriate. Can’t be entirely sure this is HF without BNP and CXR is less sensitive for pulmonary edema that US, but unlikely since you report things improved with albuterol.

it sounds like your person has chronic COPD and this all could be just COPD exacerbation with albuterol use causing tachycardia. Potassium can also be shifted by albuterol. I’m not sure they needed synthroid, certainly not to treat their acute presentation. I’m not sure they needed antibiotics as they were afebrile with very non-specific findings leukocytosis and CRP with a negative CXR. 

probably needed observation for steroids, regular nebs, keep cigarettes out of their hands, and oximetry.

[ChrisPAinED]

42 minutes ago, LT_Oneal_PAC said:

@ChrisPAinED

hey Chris, we love scenarios and helps everyone learn.

Well, if it was the TSH that was high and not the T4 I can tell you it had nothing to do with the thyroid. I assume the T4 was low since your “supervising” physician said to give synthroid. Hypothyroids doesn’t make you tachycardic. I don’t think I would have ordered a TSH at all in this presentation. They have much better reasons for tachycardia than hyperthyroidism.

you say what was deranged but not the actual levels. Potassium of 2.5 is different from 3.4, and WBC 12k is different from 20k. there is also no mention of an ABG that point to a hypercapnic issue and help determine if it was chronic or acute or acute on chronic.

You don’t mention the ROS if they complained of any systemic infectious symptoms, not any patient provided history such as increase productive cough, smoking, home medications. Would also like an age, gender, and weight.

did you just give one neb?

I do think the 500cc bolus was appropriate. Can’t be entirely sure this is HF without BNP and CXR is less sensitive for pulmonary edema that US, but unlikely since you report things improved with albuterol.

it sounds like your person has chronic COPD and this all could be just COPD exacerbation with albuterol use causing tachycardia. Potassium can also be shifted by albuterol. I’m not sure they needed synthroid, certainly not to treat their acute presentation. I’m not sure they needed antibiotics as they were afebrile with very non-specific findings leukocytosis and CRP with a negative CXR. 

probably needed observation for steroids, regular nebs, keep cigarettes out of their hands, and oximetry.

The T4 was low, the doc I was working with said it is possible that it was hyperthyroidism but that it's starting to reduce function. The potassium was 2.6 and I think they did a ABG after admission. The wbc I think was around 13.5 or 14.5, not sure if that's right because this isn't a recent case. Also thanks for being very welcoming

[MediMike]

27 minutes ago, ChrisPAinED said:

The T4 was low, the doc I was working with said it is possible that it was hyperthyroidism but that it's starting to reduce function. The potassium was 2.6 and I think they did a ABG after admission. The wbc I think was around 13.5 or 14.5, not sure if that's right because this isn't a recent case. Also thanks for being very welcoming

I'm always the one complaining about nobody doing cases and then I missed this one.

I agree with @LT_Oneal_PAC, tough to make the call without more information but with the caveat that I'm no endocrinologist I haven't heard of a situation where a high TSH and low T4 will result in symptoms of hyperthyroidism. It's the T4 that generates the increased metabolic response...but who knows. Honestly outside of myxedema type symptoms I'm not sure anybody needs to be shoving levothyroxine into somebody in the ED.

The hypokalemia could definitely be due to albuterol use, especially if they were hitting the inhaler hard before coming in. 

These folks can definitely have a significant amount of insensible fluid loss so if you've ruled out pulmonary edema then I'm all for a bolus. 

How often are y'all getting a CRP and using it for decision making?

[ChrisPAinED]

6 minutes ago, MediMike said:

I'm always the one complaining about nobody doing cases and then I missed this one.

I agree with @LT_Oneal_PAC, tough to make the call without more information but with the caveat that I'm no endocrinologist I haven't heard of a situation where a high TSH and low T4 will result in symptoms of hyperthyroidism. It's the T4 that generates the increased metabolic response...but who knows. Honestly outside of myxedema type symptoms I'm not sure anybody needs to be shoving levothyroxine into somebody in the ED.

The hypokalemia could definitely be due to albuterol use, especially if they were hitting the inhaler hard before coming in. 

These folks can definitely have a significant amount of insensible fluid loss so if you've ruled out pulmonary edema then I'm all for a bolus. 

How often are y'all getting a CRP and using it for decision making?

 

I chatted with a other PA friend that worked on this patient. It turns out levelthyroxine was cancelled because there primary care provider came in and discontinued it. I am going to be honest in the ED or at least our ED CRPs are ordered a lot and play a lot in decision making. It isn't the only thing we look at but we do get it alot. Also I do plan to do more recent scenerios later so I remember a few more details. 

[EMEDPA]

Late to the party here, but allow me to add that PE should at least cross your mind in anyone who is tachycardic and tachypneic with a low o2 sat and chest pain/pressure. Also , you didn't mention a mag level. These should be checked often (especially in the setting of hypokalemia as they trend together) as low mag levels can precipitate palpitations, fatigue, etc and mag acts as a bronchodilator in those who have SOB. I order a mag level almost every time I order a cmp. People on diuretics and/or PPIs and/or suffering from malnutrition, diarrhea, or alcoholism tend to run low. Start checking these and you will be surprised how often they are low. I have had a few really cool cases in which folks had really low levels and presented with palpitations, weakness, fatigue, sob, etc that resolved 100% with a few grams of IV mag. You can't diagnose what you don't check. 

[ChrisPAinED]

3 minutes ago, EMEDPA said:

Late to the party here, but allow me to add that PE should at least cross your mind in anyone who is tachycardic and tachypneic with a low o2 sat and chest pain/pressure. Also , you didn't mention a mag level. These should be checked often (especially in the setting of hypokalemia as they trend together) as low mag levels can precipitate palpitations, fatigue, etc and mag acts as a bronchodilator in those who have SOB. I order a mag level almost every time I order a cmp. People on diuretics and/or PPIs and/or suffering from malnutrition, diarrhea, or alcoholism tend to run low. Start checking these and you will be surprised how often they are low. I have had a few really cool cases in which folks had really low levels and presented with palpitations, weakness, fatigue, sob, etc that resolved 100% with a few grams of IV mag. You can't diagnose what you don't check. 

I had PE on my differential but patient was a young adult without a progressive hypoxia, no blood clotting risk seen on labs, patient also wheezing and O2 came up with a neb so at that point I really didn't/ don't suspect a PE. I didn't mention mag because it was ether normal or so little abnormal that I don't remember it. 

[EMEDPA]

1 minute ago, ChrisPAinED said:

I had PE on my differential but patient was a young adult without a progressive hypoxia, no blood clotting risk seen on labs, patient also wheezing and O2 came up with a neb so at that point I really didn't/ don't suspect a PE. I didn't mention mag because it was ether normal or so little abnormal that I don't remember it. 

Fair enough. Agree with LtOneal that I would not have checked a tsh on this pt. Once you see thyroid storm you won't forget it. Those folks are really over the top. The few times I have seen it, patients present in SVT acting like they are on meth and have undetectable tsh levels. 

[ChrisPAinED]

1 minute ago, EMEDPA said:

Fair enough. Agree with LtOneal that I would not have checked a tsh on this pt. Once you see thyroid storm you won't forget it. Those folks are really over the top. The few times I have seen it, patients present in SVT acting like they are on meth and have undetectable tsh levels. 

Woah. I have never seen a thyroid storm before so a bit horrified by the thought of it. 

[EMEDPA]

Anytime you think someone is on meth or cocaine, but something doesn't fit, check a tsh. Anytime someone has SVT and is acting like psych, check a tsh. These folks are all thin and very anxious. 

[ChrisPAinED]

5 minutes ago, EMEDPA said:

Anytime you think someone is on meth or cocaine, but something doesn't fit, check a tsh. Anytime someone has SVT and is acting like psych, check a tsh. These folks are all thin and very anxious. 

Yeah I will. Thanks for the tips! I really love having a opportunity with this forum to continue to learn!