Presented by Katie Ohlendorf, MD
History and Physical
CC – Altered mental status
HPI – 88 year old white male presenting to the ED with a history of being found “down” in an apartment which was noted to be in disarray. According to EMS, the pt was unable to provide any history at the time of presentation; however, was noted to exhibit slurred speech. Also, he was unable to ambulate, but was reported to be moving all four extremities equally. EMS found diltazem and synthroid in his medicine cabinet. Landlord and neighbors had not seen him in several days therefore EMS was called.
PMH, surgical history, meds, allergies, social history and family history are unknown.
PE
Vital signs: BP150/100, HR 54 and irregular, RR 22, Temp 90 degrees F (rectal)
HEENT: Normal cephalic, atraumatic. Pupils unequal but reactive bilaterally (L – 3mm, R – 2mm), eyes noted to move past midline bilaterally, no pallor, non-icteric, no papilledema. TM clear bilaterally. Oral mucosa very dry. Gag reflex intact. Neck has nuchal rigidity.
Pulmonary: Tachypneic with Kussmaul-type respirations. Clear to auscultation bilaterally.
Cardiac: Irregularly irregular rhythm with a rate of 54. No murmur, gallop, rub. Capillary refill< 4 seconds.
GI: Abdomen soft, nontender, nondistended. No masses. Positive midline supraumbilical scar. Positive bowel sounds.
GU: Negative.
Rectal: NST, prostate not enlarged. Positive guiac. Stool was dark in color.
Ext: RLE externally rotated but not shortened, old scar on right hip. No clubbing, cyanosis, or edema. Pulses intact and symmetrical – radial, femoral, and dorsal pedis.
Neuro: Patient is awake making incomprehensible sounds moving all 4 ext. equally. Gag reflex is intact. DTR’s- prolonged hyporeflexia. No clonus. Plantar reflexes down going bilaterally. No obvious facial asymmetry or focal weakness noted. Further neuro testing unable to be performed due to patient’s condition.
Lab Results and Diagnostic Studies
Sodium – 148
Potassium – 4.8
Chloride – 112
Bicarbonate – 18
BUN – 75
Creatnine – 2.3
WBC – 23.2
Hgb – 10.6
Platelets – 252
CPK – 3000
Lactate – 1.5
SDS/UDS – negative
Head CT – negative
CSF – WBC – 0, Glucose – 60, Protein – 76, RBC – 22, Gram stain negative
EKG
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Questions
- What is the likely cause of this patients altered mental status?
- Graves disease
- Uremia
- Myxedema coma
- Psychosis
- Adrenal insufficiency
- What will the thyroid studies show in myxedema coma?
| TSH level | Free T4 | T3 | |
| A | Low | High | High |
| B | Low | Low | High |
| C | High | Low | low |
| D | High | High | High |
| E | Low | Low | L |
3. What drugs should be avoided in hypothyroidism because they are known to exacerbate it?
| A | Lithium | Benzodiazepines | Motrin |
| B | Phenytoin | Lithium | Benzodiazepines |
| C | Benzodiazepines | Phenytoin | Keflex |
| D | Keflex | Rifampin | Lithium |
| E | Rifampin | Phenobarbital | Motrin |
4. What is the initial ED treatment of myxedema coma?
A. 200-500 mcg T4
B. 200-500 mcg T4 plus 100 mg IV prednisone
C. 100 mg IV prednisone
D. Supportive care
E. BB, PTU, dexamethasone and iodine
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Filed under: Intern Report
1. 3
2. c
3. b
4. a
1.) C.
2.) C.
3.) B.
4.) B.
3
C
B
B
1) C
2) C
3) B
4) A
1. C
2. C
3. E
4. B
1-3
2-C
3-D
1. 3(c)
2. c
3. b
4. b 400-500 mcg thyroxine and (300mg hydrocortisone Qd) to protect against adrenal insuff.