2. 73 year old male presents with SOB, cough,
confusion, anasarca
3. PMH
● Sick sinus syndrome who is status post
pacemaker placement 5 years ago
● Suborbital edema noted 3 months ago for
which he is planning to see a plastic surgeon
● Impaired fasting glucose
16. Take home points
- Hypothyroidism affects many organ systems
- Severe hypothyroidism mixed with an insult
can result in a myxedema crisis
- Be aware that biases exist
- Don’t know what we don’t know
17. References
● Mathew, Vivek et al. “Myxedema Coma: A New Look into an Old Crisis.” Journal of Thyroid
Research 2011 (2011): 493462. PMC. Web. 9 Oct. 2017.
● Kim, J. (2017). Myxedema — NEJM. New England Journal of Medicine. Retrieved 19 October 2017,
from http://www.nejm.org/doi/full/10.1056/NEJMicm1403210#t=article
● Pathology definition - Myxedema. (2017). Medical Zone. Retrieved 19 October 2017, from
http://www.medicalzone.net/pathology-definition---myxedema.html
● Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1
(2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain.
● Icons: thenounproject.com, pvhc.com, shareicon.net, iconfinder.com, moziru.com,
commons.wikimedia.com, endlessicons.com
CT chest with infiltrate => Antibiotics started
CT/CTA head => no e/o CVA (Unable to do MRI due to pacemaker)
Transthoracic Echocardiogram
Ejection Fraction < 40 (Down from 60 a year earlier)
Global hypokinesis
CVP of 3
Day 8: TSH is 93
Given his hx of SSS, periorbital edema, and confluence of symptoms while hospitalized assuming that a TSH had been checked
In a world with many handoffs, this can play a significant impact.
Low CVP
Anasarca instead of LE edema
Dysarthria without any focal neuro deficits
Can’t get an MRI due to pacemaker -> Accept dx of CVA
Not proceeding to cardiac cath while in hypoxic resp failure due to PNA