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Myxedma crisis
- 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
- 4. Diagnostics: Labs ● Troponin 0.16 ● BNP 1341 ● Glucose 62 ● Elevated AST/ALT ● Random cortisol 13
- 5. Diagnostics: Imaging ● CT chest ● CT/CTA head ● Transthoracic Echocardiogram
- 6. Day 5 First stool of hospital stay
- 7. Patient Issues ● Hypoxic respiratory failure ● Pneumonia ● NSTEMI ● Acute CHF ● CVA ● Hypoglycemia ● Constipation
- 9. Cardiovascular Bradycardia Hypotension Low cardiac output Neuropsychiatric Confusion Lethargy Coma Respiratory Hypoxia Pleural effusions Pneumonia (precipitating factor) Renal / H2O metabolism Hyponatremia Anasarca Bladder atony Gastrointestinal Constipation Toxic megacolon Metabolic Hypothermia Hypoglycemia Clinical / lab features of myxedema crisis
- 12. Assumption bias ● Taking for granted that something has already been done
- 13. Anchoring ● Focus on early signs/symptoms ● Tendency to regress toward the anchor ○ Ignore other information
- 14. Premature closure / Search satisfaction ● Accepting initial diagnosis ● Calling off search once reasonable explanation found
- 15. Availability Heuristic ● Recent / more common diagnosis are easily brought to mind
- 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
- 18. Questions?
Hinweis der Redaktion
- Noted to have dysarthria, SBPs to 60s, ↑ Hypoxia
- 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
- Admit multiple PNAs, CHFs, TIAs in