Vol 2:6 Question
Altered Mental Status
A 74-year-old lethargic woman is brought to the ED by her family. Her daughter states that the patient has been progressively somnolent over the last week and could not be woken up today. The patient takes medications for diabetes, hypertension, hypothyroidism and a recent ankle sprain, which is treated with a hydrocodone/acetaminophen combination. In the ED, the patient is profoundly lethargic, responsive only to pain, and has periorbital edema and delayed relaxation of the deep tendon reflexes. Her blood pressure is 145/84 mm Hg, heart rate is 56 beats per minute, temperature is 94.8°F, and respiratory rate is 12 breaths per minute. Her fingerstick glucose is 195 mg/dL. Which of the following is the most likely diagnosis?
a. Hypoglycemia
b. Myocardial infarction
c. Stroke
d. Myxedema coma
e. Depression
Please submit your answer in the "comment" section. The person with the most correct entries at the end of six weeks will receive a copy of the book PreTest Emergency Medicine.
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16 comments:
The patient has a history of hypothyroidism and takes meds for it. A myxedema coma can be caused by not taking one's thyroid medications, which is possible (and often probable) in the elderly. The periorbital edema is symptomatic of such a coma, along with a low body temperature, slow heart rate and depressed respirations. It is more likely to occur in the elderly, especially women, and increasing lethargy before the coma can be symptomatic as well.
Therefore, I hazard the guess that the patient has D, a Myxedema Coma.
However, given the fact that this fits all the symptoms so perfectly and special mention was made of the patient's ankle sprain with hydrocodone/acetaminophen treatment, I'm betting that I'm wrong. But who knows, it'd be cool *not* to be wrong!
Myxedema coma!
Answer - D, Myxedema coma
With the low body temp, periorbital edema and delayed relaxation of the deep tendon reflexes as well as the medical history, that would be the most likely.
Glucose levels rule out Hypoglycemia. The lack of sudden onset or asymetric symptoms would lead me away from stroke. Normal respiration and not significantly low heart rate in addition to the other information doesn't lead me to MI. The obvious physical symptoms rule out depression.
BTW -- What are the latest standings?
Myxedema coma.
wongml
d. Myxedema coma
d
d. Myxedema coma
d. Myxoedema coma.
D. Myxedema coma
Her history of hypothyroidism could lead to this problem, and the reduced mental status.
D. Myxedema coma
The answer is
d) myxedema coma
d. myxedema coma
Myxedema coma
myxedema coma
Standings will be out at the end of the eight week.
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