A woman with neck pain and shortness of breath

An 86 year old white woman with a history of angina, hypertension, and recurrent urinary tract infections presented after two days of worsening shortness of breath but no cough or fever. The previous week she had been a patient in a rehabilitation ward after a two week admission with a urinary tract infection and acute confusion. Her regular drugs comprised bisoprolol, simvastatin, and lansoprazole.

On examination, her temperature was normal, her heart rate was 144 beats/min and irregular, her blood pressure was 132/76 mm Hg, and she was mildly tachypnoeic, with an oxygen saturation of 93% on air. Her jugular venous pressure was raised and she had bilateral crepitations on auscultation.

Palpation of the neck identified a tender diffusely enlarged thyroid gland with no discrete nodules. Other signs of thyroid disease, including eye signs, were absent. The rest of the examination was unremarkable.

Electrocardiography confirmed new atrial fibrillation, with a ventricular rate of 140 beats/min. Cardiomegaly and pulmonary oedema were seen on chest radiography.

Blood tests showed thyroid stimulating hormone (TSH) 0.02 mIU/L (reference range 0.35-4.94), free triiodothyronine (T3) 12.3 pmol/L (2.6-5.7; 1 pmol=65 pg/dL), and free thyroxine (T4) 57.6 pmol/L (9.0-19.0; 1 pmol=0.08 ng/dL).