Thanks to those who put their heads above the parapet and contributed. To
some extent it makes us feel better that no-one on the list so far has asked
for the simple test that gave the answer. The textbook describes (in normal
size print)
Life threatening
Usually abrupt in onset and related to a precipitating factor (surgery,
infection?)
Often an exacerbation of a known pre-existing condition (not in this case).
Fever almost invariable.
CVS - tachycardia, arrythmia, CCF, shock
CNS - agitation, tremor, restlessness, mania, delirium, stupor, coma
Abdominal - pain, jaundice, diarrhoea, vomiting, hepatomegaly
Of the above her features were mostly CNS - no shock, she maintained sinus
rhythm and has no liver signs.
By testing all we could think of we found TSH low at 0.01; Free T4 high 52.8
(9-24 normal)
Diagnosis - Thyroid crisis
The bruises on her arms were caused a couple of days before when she had a
short episode of agitation. I presume the head bruises were a mixture of
old and new from delirium.
My initial worry was that she seemed psychiatric (puerperal) and almost too
well, but did think of SAH, so that is why I didn't dive in with the full
hit immediately. With retrospect it would not have helped her.
Her care was by our physicians and she was transferred to another hospital
HDU (bed problem here). She remains haemodynamically stable but sedated
with diazepam because of delirium. Treated with Carbimazole, Iodine,
Propranolol and Dexamethasone.
Thyroid function is not on our list of routine bloods for acute confusion.
The lab boys don't like doing them routinely as it seems to be a low return
test. I doubt it will become routine here.
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