A 70-year-old man is brought to the emergency department by his nephew after being found poorly responsive at home. The patient lives alone and had not been seen for 2 weeks. His family has noticed that he has been confused and less active over the past few months. Medical history is unknown, and family members report only that the patient takes several pills a day for "heart issues," blood pressure, and headaches. Emergency department records show a recent visit for back pain, which was treated with opioid analgesics and centrally acting muscle relaxants.
Temperature is 35 C (95 F), blood pressure is 120/100 mm Hg, pulse is 55/min, and respirations are 10/min. The patient is lethargic and oriented only to person. He has a puffy face and hands and an enlarged tongue. Pupils are normal and reactive. The neck is supple. Cranial nerve, cardiac, pulmonary, and abdominal examinations are unremarkable. The patient moves all extremities on command.
Laboratory results are as follows:
Chest x-ray shows a mildly enlarged cardiac silhouette and no infiltrates. ECG shows sinus bradycardia, a QTc interval of 450 msec, and T-wave flattening. Additional laboratory testing is pending.
Which of the following is the most appropriate next step in management of this patient?

Question

A 70-year-old man is brought to the emergency department by his nephew after being found poorly responsive at home.  The patient lives alone and had not been seen for 2 weeks.  His family has noticed that he has been confused and less active over the past few months.  Medical history is unknown, and family members report only that the patient takes several pills a day for "heart issues," blood pressure, and headaches.  Emergency department records show a recent visit for back pain, which was treated with opioid analgesics and centrally acting muscle relaxants.
Temperature is 35 C (95 F), blood pressure is 120/100 mm Hg, pulse is 55/min, and respirations are 10/min.  The patient is lethargic and oriented only to person.  He has a puffy face and hands and an enlarged tongue.  Pupils are normal and reactive.  The neck is supple.  Cranial nerve, cardiac, pulmonary, and abdominal examinations are unremarkable.  The patient moves all extremities on command.
Laboratory results are as follows:
 Chest x-ray shows a mildly enlarged cardiac silhouette and no infiltrates.  ECG shows sinus bradycardia, a QTc interval of 450 msec, and T-wave flattening.  Additional laboratory testing is pending.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_95ed_30b2_853d_2ba49c184a54_MD0002_00 Myxedema coma (hypothyroid crisis) is characterized by altered mental status, hypothermia, hemodynamic instability, reduced cardiac output, and disordered breathing. Specific signs may be absent, but myxedema (excess deposition of mucin in soft tissues) involving the face, tongue, and extremities is strongly suggestive. Diastolic hypertension and bradycardia can often be seen, and hypoglycemia is common (due to hypothyroidism or concurrent adrenal insufficiency). Pre-existing hypothyroid symptoms are often present for several months before rapid clinical deterioration, which is often triggered by acute illness (eg, infection) or medication (eg, opioids). Myxedema coma is a life-threatening condition (30%-40% mortality), and treatment should be initiated without waiting for the results of thyroid function studies (serum TSH, free T4). Most experts advise giving both levothyroxine (T4) and liothyronine (T3) intravenously until the patient's condition stabilizes. Because adrenal insufficiency may coexist, patients with myxedema coma should also receive intravenous hydrocortisone until adrenal insufficiency is excluded by biochemical testing. In addition, empiric broad-spectrum antibiotics should be considered as signs of infection are often suppressed. (Choice A) Fat pad biopsy is a diagnostic test for amyloidosis, which can present with macroglossia, renal disease, cardiomyopathy, and peripheral neuropathy. However, central nervous system involvement and hypothermia occur less often. (Choice C) Although patients with chronically uncontrolled diabetes may develop hypoglycemic symptoms with blood glucose in the low-normal range, altered mental status in a nondiabetic patient is unlikely unless glucose is <50-55 mg/dL. Severe hypothyroidism can cause moderate hypoglycemia (especially in patients with coexisting adrenal insufficiency), which typically corrects with thyroid hormone therapy and glucocorticoids. (Choice D) Opioid toxicity can cause abnormal mental status and hypoventilation, often with miosis and decreased bowel sounds. However, macroglossia, hypothermia, gradual worsening of mental status, and facial edema are more consistent with myxedema coma. (Choice E) Wernicke-Korsakoff syndrome may present with altered mental status and hypothermia. Characteristic findings also include oculomotor dysfunction and disordered gait. This patient's myxedema and normal cranial nerve findings are more consistent with myxedema coma. Educational objective: Myxedema coma is a life-threatening condition characterized by altered mental status, hypothermia, and nonpitting swelling of the extremities, face, and tongue. Treatment with intravenous levothyroxine (T4) and liothyronine (T3) should not be delayed while awaiting results of thyroid function tests. __________ References: Myxedema coma. (http://www.ncbi.nlm.nih.gov/pubmed/17712058)

A 70-Year-Old Man Is Brought to the Emergency Department by His