A woman with neck pain and shortness of breath

Studies have shown that the use of ultrasonography or fine needle aspiration can greatly alter the clinical management of patients with abnormal results on physical examination. 11 Isotope uptake scans using pertechnetate (an anionic analogue of iodine) labelled with technetium-99m help to distinguish between Graves' disease (homogenous increased tracer uptake in the enlarged gland), thyroiditis (absent or low uptake), multinodular goitre (heterogeneous uptake), and a solitary toxic nodule (focus of intense activity and suppression of the normal gland). Because the patient's uptake level borders on the normal range and it was taken after she had been stabilised from the acute hyperthyroid state, this scan may represent the start of the recovery period. If the clinical diagnosis of subacute thyroiditis is not certain, initially treat with carbimazole pending further investigation to determine the diagnosis. Because she had been on a rehabilitation ward before admission, continued multidisciplinary rehabilitation is also a priority. [beta] blockers are the treatment of choice in hyperthyroid heart failure, but caution is needed in hyperthyroid patients with other causes of cardiac failure. Treatment with aspirin seemed to settle the pain. Because of the risk of falls, and after discussion with the patient, anticoagulation with aspirin was thought to be the most appropriate treatment.