Internist Misses Hyperthyroidism Leading to Fatal Arrhythmia

This case involves a fifty-year-old female who sustained a stroke from undiagnosed atrial fibrillation and hyperthyroidism. For ten years, this patient was being seen by an internist for routine visits. The woman did not have any complaints. A blood pressure reading of 135/80 was recorded at one visit, which was elevated compared to her baseline. The doctor indicated that he would monitor her blood pressure and scheduled her for an appointment in one month. At the next visit, her blood pressure was 142/90, warranting medical intervention. The patient was initiated on medication and was scheduled for a follow-up in three months. Before her next appointment, the patient began to develop right facial dropping, weakness on the right side of her body, and began to not make sense while speaking at home. She was brought to the emergency department where she was diagnosed with a stroke. EKG revealed atrial fibrillation, a condition that contributed to her stroke. Laboratory values in the hospital revealed grossly elevated thyroid hormone levels indicating uncontrolled hyperthyroidism. Upon reviewing her medical records, past labs ordered by the internist showed elevated thyroid hormone levels, which were never communicated to the patient.

Question(s) For Expert Witness

1. Was this patient properly managed for her medical conditions, and what could have been done to prevent these occurrences from happening?

Expert Witness Response

This patient was not properly managed by her internist. This patient was correctly diagnosed with hypertension, however its cause was never further investigated. One common cause of hypertension is hyperthyroidism. Other symptoms of hyperthyroidism include weight loss, increased deep tendon reflexes, diarrhea, heat intolerance, chest pain, palpitations, and tremors. One serious complication of hyperthyroidism is atrial fibrillation, a cardiac arrhythmia that can lead to stroke. Hyperthyroidism should have been diagnosed and treated in this patient based upon symptoms, physical findings, and laboratory values. Treatments include medications that inhibit thyroid hormone synthesis (propylthiouracil, methimazole) and thyroid surgery. A diagnosis could have prevented the development of atrial fibrillation and subsequent stroke. Even if she did develop atrial fibrillation, the physician could have prescribed her an anti-coagulant to prevent the emergence of stroke.