Introduction
Myxedema coma, a rare presentation of hypothyroidism, is defined as severe hypothyroidism presenting with decreased mental status, hypothermia, as well as multiple organ dysfunction. It is a medical emergency, associated with a high mortality rate. We report the case of myxedema coma presenting as altered mental status in the setting of acute renal failure.
Case Presentation
An 83 year old male with past medical history of coronary artery disease, hypertension, hypothyroidism, stage four bladder cancer and bilateral hydronephrosis with recent bilateral stent placement was brought to the emergency department at an outlying hospital by his son due to increased lethargy and confusion. He was found to have acute renal failure, and
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His initial blood pressure was 113/60 mmHg, her heart rate was 50 beats/min, and his oxygen saturation was 100%. His Glasgow Coma Scale was 8. His physical exam was also remarkable for dry mucous membranes, and distant heart sounds, in addition to weak lower extremity pulses and non-pitting edema. No thyroid goiter was palpable.
Laboratory investigations on admission showed a hemoglobin of 10.2, impaired renal function with creatinine of 7.3mg/dl and potassium of 7.1mmol/L. Nephrology service was contacted and hemodialysis was initiated. Mental status did not improve following dialysis, therefore a computed tomography scan (CT) of the head and a Thyroid stimulating hormone level (TSH) were ordered to rule out other causes of altered mental status. His CT scan did not show any acute findings. His TSH level was 51.4UIU/ML and his free T 4 level was 0.1NG/DL.
The patient was immediately started on intravenous levothyroxine sodium hydrate (100 μg/day) and intravenous dexamethasone (4mg), in addition to supportive measures. His mental condition improved dramatically within a few days along, and his free t4 normalized. His kidney function improved after requiring one session of
Dr.Bain ordered a CT scan of Cynthia’s chest to rule out a possibility of an aneurism. Dr. Bain also did another CT scan of Cynthia’s abdomen to evaluate her liver. Additional lab work and thyroid testing was done. Around 5:00pm she was discharged with instructions to follow up with her primary care physician Leah Avera, M.D within one week. In Cynthia’s discharge summary that was signed by Dr. Pesante, states, in part, "it just seems like Cynthia’s problem may have more so been either some kind of infectious process or possibly a thyroid
Examination revealed an oxygen saturation of 98% and blood pressure of 145/90. Oropharyngeal inspection revealed significant crowding (Mallampati class 3) with macroglossia. Chest auscultation was clear and two heart sounds were audible with nil else.
Dr. Murray, the chief resident who arrived around 8:00pm, charted Lewis’ heart rate as normal and noteds a probable ileus; however, nursing documentation at the same time recorded a heart rate of 126 beats per minute (Monk, 2002). Subsequent heart rates at midnight and 4:00am arewere charted as 142 and 140 beats per minute respectively without documented intervention (Monk, 2002 ). On Monday morning Lewis noted that his pain suddenly stopped after being very constant and staff charted that they were unable to get a blood pressure recording in either arm or leg from 8:30-10:15am despite trying multiple machines (Monk, 2002; Solidline Media, 2010).
Hypothyroidism develops when the thyroid gland does not produce enough of certain hormones. (“Hypothyroidism”, n.d.). Hypothyroidism can be broken down even further. The two types of hypothyroidism are congenital hypothyroidism or acquired hypothyroidism. According to Porth 2011, “Congenital hypothyroidism develops prenatally and is present at birth. Acquired hypothyroidism develops later in life because of primary disease of the thyroid gland or secondary to disorders of hypothalamic or pituitary origin.” (p. 786). Some common symptoms include increased sensitivity to cold, dry skin, fatigue, constipation, drowsiness, hypothermia and muscle weakness (“Hypothyroidism”, n.d.).
The kidneys play a major role in the blood composition and volume , the excretion of metabolic wastes in the urine, the control the acid/base balance in the body and the hormone production for maintaining hemostasis. The damages to the GBM in the glomeruli alter filtration process that allows the protein and red blood cells to leak into the urine. Loss of protein like albumin in the urine results in a decrease of their level into the blood stream. Consequently, this patient’s blood reveals a decreased albumin (Alb) value of 2.9 g/dL, decreased serum total protein value of 5 .0 g/dL and in the urine presents of the protein and the RBCs. Impaired filtering capacity result in inability of kidneys to excrete excretory products like electrolytes and metabolic waste products that will then accumulate in the blood. Furthermore, inability of distal convoluted tubules to excrete sufficient quantities of potassium, sodium, magnesium (Mg), chloride (Cl), urea, creatinine (Cr), alkaline phosphatase (Alk Phos), and phosphate (PO4) results in their elevation in the blood. His laboratory values reveal an increased of sodium value of 149 meq/L, an increase of potassium value of 5.4meq/L, increased chloride value of 116 meq/L, increased blood urea nitrogen (BUN) serum of 143 mg/dL, and increased creatinine serum of 7.14 mg/dL. The other abnormal blood tests associated with a loss of kidneys’ filtration property identify in this patient are related to an increase of alkaline phosphatase value of 178 IU/L, increased magnesium value of 3.8mgdL, and increased phosphate (PO4) value of 5.9 mg/dL .
What is the purpose of each of the medications the patient is on? Why is this patient receiving them?
The neurological problems associated with chronic renal failure and its consequent treatment, namely hemodialysis, can be either acute or chronic. When acute, the patient develops a set of symptoms collectively referred to as dialysis disequilibrium syndrome (DDS). This syndrome presents with a transient loss or alteration of the sense of equilibrium due to disturbances to the vestibular sy...
Graves’ disease is a thyroid disorder with an unknown cause, although there is an increased risk for those developing it if other family members have it. It is eight times more common in women than in men. It usually occurs in those who are over the age of 20, though children are sometimes affected. Graves’ disease affects more than 3 million people and there are approximately 60,000 new cases of Graves’ disease in the US each year. It accounts for 60% of hyperthyroidism cases. Graves’ disease has many possible symptoms which include fatigue, tremors, double vision, insomnia, anxiety, muscle weakness, unstable weight, nervousness or irritability, restlessness, anxiety, increased sweating, brittle hair and nails, heat intolerance, rapid and irregular heartbeat, freque...
Today in America thyroid disease is becoming a much larger issue and the worse part of this problem is that many people are not yet diagnosed. This is due to the lack of education and awareness about thyroid disease. There are many different types of diseases but the one that I am passionate about is hypothyroidism. Hypothyroidism, or underactive thyroid is when the thyroid is no longer able to produce triiodothyronine, also known as T3 and thyroxine, also referred to as T4. Some of the symptoms include unexpected weight gain, tiredness, depression, or slow movements and thoughts. Most of the time many people notice the way that their bodies act on what they are feeling to their physicians. Many Americans struggle with this disease that
The following presentation will help this class in the teaching of a patient with hypothyroidism. The expected outcome of this presentation for the patient will be as follows:
On admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings. J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed several abnormal labs. A red blood cell count of 3.99, white blood cell count of 22.5, hemoglobin of 10.9, hematocrit of 33.7%, sodium level of 13, potassium level of 3.1, carbon dioxide level of 10, creatinine level of 3.24, glucose level of 200, and a BUN level of 33 were the abnormal labs.
The thyroid gland is found in the front of the neck and produces two main hormones. The hormones are called thuroxine (T4) and Triiodothyronine (T3). Together these hormones regulate the body’s metabolism by increasing energy use in cells, regulate growth and development, help to maintain body temperature and aid in oxygen consumption. These two hormones are regulated by hormones produced by the hypothalamus and pituitary gland. The hypothalamus senses changes in body’s metabolic rate and releases a hormone known as thyropin-releasing hormone (TRH). This hormone then flows through connecting vessels to the pituitary gland which signals it to release another hormone. This hormone is known as thyroid-stimulating hormone (TSH). TSH then makes its way to the bloodstream until it reaches the thyroid where it is then signaled to activate T3 and T4 production [1]. This mechanism is controlled by a negative feedback loop meaning that when there is a sufficient amount of thyroid hormones in the blood stream, this will signal back to stop production of thyroid stimulating hormones. Complications occur when the thyroid hormones keep increasing even though there is already a sufficient amount of T3 and T4 in the blood stream. This process of over expression of thryroid hormones is known as hyperthyroidism. Hyperthyroidism is a general term that includes any disease that has a consequence of an overabundance of thyroid hormones. Hyperthyroidism is a general term but there are many variant diseases that are in the hyperthyroidism category. These diseases include diffuse toxic goiter, Basedow’s disease, thyrotoxicosis, Parry’s and Graves’ disease.
Among these disorders are hypothyroidism and hyperthyroidism. Hypothyroidism is a disorder in which one is diagnosed for having and underactive thyroid. The probability for women over the age of sixty to develop an underactive thyroid is higher than those of other individuals. If left untreated it can potentially lead to obesity, joint pain, heart disease, and other health complications. On the contrary, hyperthyroidism is a disorder in which a person is diagnosed for having an overactive thyroid. This can cause nervousness and anxiety, hyperactivity, unexplained weight loss, and swelling of the thyroid gland which causes a noticeable lump to form on throat (known as a
As a first step, a mental status exam of Randal was taken. Clad in business-casual attire, Randal was physically appearance appropriate. His thought processes were reasonable and he displayed proper affect. He had stated that his mood was depressed and anxious. Intellectually Randal had an extensive vocabulary and seemed extremely bright. In regards to Randal’s sensorium, he was oriented times three. Although falling in the overweight category, Randal otherwise appeared healthy and had no adverse health history. Randal was asked to get lab work assessing the functioning of his thyroid, as that often can influence anxiety levels. It was decided that Randal was neither a candidate for psychological and personalit...
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.