Clinical Case 1

Edward Ng, D.O., M.S.

Francis Villanueva, D.O.


This is a 92-year-old male with significant medical history including CKD, hypertension, dementia, hypothyroid, BPH, brought in by EMS from the nursing home with altered mental status.  Per EMS, patient is at baseline A&O x3 which was how he was this morning.  Patient arrived to the ED at 0945, and 15 minutes prior to arrival patient was being fed when he abruptly began having a “seizure” lasting about 1 minute.  Patient was altered and confused and an apparent postictal state.  On transport patient had bradycardia down into the 30-40s and 0.5 atropine was given which brought his heart rate back up into the 60s.  Patient's blood pressures were also in the systolic 70s as low as 60s.  Patient is not responding verbally and no history is obtainable from him.

ROS: unable to obtain 2/2 acuity of condition/patient unresponsive

Physical Exam


Ventricular rate: 49

Incomplete LBBB


Is this patient having a stroke?


Chest X-Ray

Poor inspiratory effort.  Overlying leads and wires.  Heart size prominent unchanged.  Calcification of aortic arch.  Linear scarring left lung base. Reticular opacities both lung bases likely atelectasis.  Confluent interstitial and groundglass opacities perihilar regions on the right lung base could represent areas of atelectasis and or developing interstitial edema.  Probable small left-sided pleural effusion.  Linear lucency at the right neck could be artifactual.  Follow-up advised.  No pneumothorax.




Lactic Acid

Blood Gas

Troponin, PT, PTT, Magnesium


What test do we order next?

Click to see answer

Diagnosis: Myxedema Coma




Our patient:

Temp: 86.5ºF (30.3ºC)

HR: 53

Free Triiodothyronine: 0.8 pg/mL

Precipitating Factors



Work Up


Oxygen reserve much lower even with adequate pre-oxygenation 

Prone to much faster desaturations 

Airway collapse, making direct laryngoscopy difficult

Disposition: ICU


Cimino-Fiallos, Nicole. “Decompensated Hypothyroidism.”,

Farkas, Josh. “Decompensated Hypothyroidism (‘Myxedema Coma’).” EMCrit Project, 11 Feb. 2023,

Eledrisi, Mohsen s. “Myxedema Coma or Crisis.” Practice Essentials, Pathophysiology, Epidemiology, Medscape, 29 June 2022,