Thyroid Storm Case Report Form
Record the essential details of a thyroid storm case, including presentation, objective findings, treatment, and outcome.
Case Identification
Case reference number
*
Patient age
*
Patient sex/gender
*
Female
Male
Intersex
Self-described
Prefer not to say
Clinical Presentation
Date/Time of Symptom Onset or Presentation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Main Presenting Symptoms
*
Fever
Palpitations
Agitation
Tremor
Diarrhea
Vomiting
Altered Mental Status
Other
Overall Symptom Severity / Acuity
*
Mild
1
2
3
4
5
6
7
8
9
Critical
10
1 is Mild, 10 is Critical
Objective Findings
Vital signs at presentation
*
Rows
Temperature
Heart rate
Blood pressure
Respiratory rate
Oxygen saturation
Initial presentation
Key laboratory or diagnostic findings
Trigger, Management, and Outcome
Suspected precipitating factor(s)
*
Infection
Medication nonadherence
Recent surgery
Contrast exposure
Pregnancy
Parturition
Trauma
Acute illness
Other
Treatments administered
*
Beta-blocker
Antithyroid medication
Iodine
Corticosteroid
Supportive care
Cooling measures
IV fluids
Other
Patient outcome/disposition
*
Improved
Admitted
ICU
Transferred
Discharged
Deceased
Clinician notes or follow-up plan
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