A 28 year old postpartum woman with right sided chest discomfort: case outcomeBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7542.643 (Published 16 March 2006) Cite this as: BMJ 2006;332:643
All rapid responses
Really enjoyed this exercise and appreciate my mention in the review.
Also a big thank you to all who joined in the Web discussion - excellant
Went off on a hypothetico-deductive tour de force maybe. The "closed"
nature of the questions after the second part made me not reveal all of
what I thought in case it spoiled the process - maybe not ideal for what
is meant to be an educational process.
My postulate was, given sub-therapeutic thyroid replacement in the
first part (we are never given an explanation and surely Mrs Patel's GP
should have been involved in this publication) the sequence of events
could have been:
1) (unrecoginised) peri-partum thyrotoxicosis
2) Secondary dilated cardiomyopathy (a recognised association)
3) Then a finding of hypothyroidism (the usual course, post -toxic) with
the GP currently titrating the dose, but of course against the pmh of
hyperthyroidism Mrs Patel is dropping her T3 slowly, hence the low dose at
What I failed to "buy" was the effort relation of the chest pain.
So how do I sqaure my hypothetico-deductive approach with the
Bayesian approach? Well everything is rare to Mrs Patel and I am not
convinced my proposed diagnosis is less likely than that eventually
What I would say is 2 things:
1) Read the question - if something looks odd (the Levothyroxine
dose) pursue it (for many respodants missed this).
2) But don't forget classic symptoms - chest pain on effort remains
strongly suggestive of Coronary Heart Disease (or aortic stenosis) -
regardless of any other factors.
Excellant Interactive Discussion - please can we have more.
Competing interests: No competing interests