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 55yr old man with fever and AF and......  



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  #1

A 55-year-old man is admitted to the hospital with fever, obtundation, and rapid atrial fibrillation. On physical examination, he is hot and flushed. His pulse rate is 180/min, his blood pressure is 165/50 mm Hg, and his temperature is 40 °C (104 °F). His thyroid gland is enlarged to twice its normal size with a loud bruit. Bilateral exophthalmos is present. Rales are heard on the right. Chest radiograph shows pneumonia is present. Thyroid function tests are done.

Which of the following regimens should be started while awaiting the results of these tests?

(A) Digoxin
(B) Digoxin and a beta-blocker
(C) Digoxin, propylthiouracil (PTU), and a beta-blocker
(D) Digoxin, ipodate, a beta-blocker, and dexamethasone
(E) Digoxin, propylthiouracil, ipodate, a beta-blocker, and dexamethasone




  #2

The answer is C? treatment ofThyroid storm plus atrial fibrillation.


  #3

I´m concerned about the combination of beta blockers and digoxin. Is it ok (safe) to give both?? Probably I would give beta blockers plus PTU. Beta blockers (propanolol, for instance) alone can lower ventricular response and control other adrenergic symptoms. Maybe digoxin will overcome propanolol´s negative inotropism?? :?

This guy is hyperthermic, obtunded and tachycardic. He needs urgent treatment, and though we do not have lab results from his thyroid-hormone status, he shows enough signs to make a diagnosis of Grave´s Disease: exoftalmos, goiter, bruit, hyperthermia, flushing; pulmonary rales on the right might be a indicator of the illness that precipitated his thyroid storm (pneumonia). PTU is indicated.

Ipodate and dexametasone are also beneficial in thyroid storm. So option E sounds right. However, ipodate should be given at least an hour after starting PTU to avoid I ions to be used to produce more hormone.

I think it´s.... mmm... C.

Please explain about using beta blockers PLUS digoxin.


  #4

carvedilol and digoxin better together A-fib than either one alone. Carries a greater risk of AV block.


  #5

my guess is D.
Digoxin for AF, propranolol is rapidly effective both orally n IV in thyroid crisis and ipodate can help with inhibtion of thyroid hormones... furthermore Dexamethasone for adrenal support.





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