Case Presentation The patient is a 60-year-old white female presenting to the emergency department with acute onset shor

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Case Presentation The Patient Is A 60 Year Old White Female Presenting To The Emergency Department With Acute Onset Shor 1 (71.7 KiB) Viewed 56 times

Case Presentation The Patient Is A 60 Year Old White Female Presenting To The Emergency Department With Acute Onset Shor 2 (57.25 KiB) Viewed 56 times

Case Presentation The Patient Is A 60 Year Old White Female Presenting To The Emergency Department With Acute Onset Shor 3 (39.95 KiB) Viewed 56 times

Case Presentation The Patient Is A 60 Year Old White Female Presenting To The Emergency Department With Acute Onset Shor 4 (68.51 KiB) Viewed 56 times

Case Presentation The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep. She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea. She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that are ne new-onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath. There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies.
Physical Exam Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, HT 160 cm, WT 100 kg, BMI 39.1, and O2 saturation 90% on room air. Constitutional: Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets. HEENT: Head: Normocephalic and atraumatic Mouth: Moist mucous membranes ► Macroglossia ► Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Bilateral periorbital edema present. Neck: Neck supple. No JVD present. No masses or surgical scarring. Throat: Patent and moist Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong pulses in all four extremities. Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement bilaterally. The patient was barely able to finish a full sentence due to shortness of breath.
Differential Diagnosis Acute on chronic COPD exacerbation Acute on chronic renal failure Bacterial pneumonia Congestive heart failure ► NSTEMI Pericardial effusion → Hypothyroidism ► Influenza pneumonia Pulmonary edema Pulmonary embolism
Discussion a Despite the name myxedema coma, most patients will not present in a coma status. This illness is at its core a severe hypothyroidism crisis that leads to systemic multiorgan failure. Thyroid hormones T3, and to a lesser extent. T4 act directly on a cellular level to upregulate all metabolic processes in the body. Therefore, deficiency of this hormone is characterized by systemic decreased metabolism and decreased glucose utilization along with increased production and storage of osmotically active mucopolysaccharide protein complexes into peripheral tissues resulting in diffuse edema and swelling of tissue. (1) Myxedema coma is an illness that occurs primarily in females at a rate of 4:1 compared to men. It typically impacts the elderly at the age of greater than 60 years old, and approximately.90% of cases occur during the winter months. Myxedema coma is the product of longstanding unidentified or undertreated hypothyroidism of any etiology. Thyroid hormone is necessary throughout the body and acts as a regulatory hormone that affects many organ systems.[2]In cardiac tissues, myxedema coma manifests as decreased contractility with subsequent reduction in stroke volume and overall cardiac output. Bradycardia and hypotension are typically present also. Pericardial effusions occur due to the accumulation of mucopolysaccharides in the pericardial sac, which leads to worsened cardiac function and congestive heart failure from diastolic dysfunction. Capillary permeability is also increased throughout the body leading to worsened edema. Electrocardiogram findings may include bradycardia and low-voltage, non-specific ST waveform changes with possible inverted T waves.