Marissa Bennett
Admission Snapshot
Chief Complaint
“I feel exhausted all the time and I can't seem to get warm.”
Patient presents with worsening fatigue, cold intolerance, constipation, slowed thinking, and generalized weakness. Her daughter reports that today Marissa became increasingly difficult to keep awake and nearly fell while walking to the bathroom.
Patient Profile
DOB 02/14/1978 • 5 ft 5 in (165 cm) • 181 lb (82.1 kg) • BMI 30.1
Isolation Status: Standard Precautions
Medical History
- Hashimoto thyroiditis diagnosed 8 years ago
- Primary hypothyroidism
- Hyperlipidemia
- Chronic constipation
- Obesity
- No known history of adrenal insufficiency
- No known history of heart failure
Home Medications
- Levothyroxine 125 mcg PO every morning — patient reports inconsistent use for approximately 2 months.
- Atorvastatin 20 mg PO nightly — hyperlipidemia.
- Polyethylene glycol 17 g PO daily PRN — constipation.
Recent History
Marissa recently lost her employer-sponsored prescription coverage and began rationing her levothyroxine. She eventually began taking the medication only intermittently.
During the last several weeks, her family noticed increasing sleep, slowed movement, dry skin, facial puffiness, decreased appetite, constipation, and worsening sensitivity to cold.
Emergency Contact
Jordan Bennett • Daughter
589-216-XXXX
Insurance
BlueCross BlueShield
Current Care Status
Emergency Department evaluation in progress. Patient is a Full Code and remains on Standard Precautions.
Patient Timeline
Marissa arrives with progressive fatigue, cold intolerance, slowed cognition, constipation, and generalized weakness. Her hypothermia, bradycardia, hyponatremia, low glucose, and increasing somnolence raise concern for severe untreated hypothyroidism with potential for further decompensation.
Chief Complaint
“I'm exhausted all the time, I can't get warm, and today I almost fell because I felt so weak.”
History of Present Illness
Marissa Bennett is a 48-year-old woman with Hashimoto thyroiditis and primary hypothyroidism who presents with approximately six weeks of worsening fatigue, cold intolerance, constipation, generalized weakness, slowed speech, increased sleep, and difficulty concentrating.
Her daughter reports that Marissa's movements and responses have become noticeably slower. Marissa admits that she has taken levothyroxine inconsistently for approximately two months after experiencing difficulty obtaining the medication. She initially rationed doses and has taken the medication only intermittently during the last several weeks.
During this period, her family has noticed worsening facial puffiness, dry skin, decreased appetite, constipation, and increasing sleepiness. This morning she became weak and nearly fell while walking to the bathroom.
She denies chest pain, palpitations, vomiting, diarrhea, recent head injury, or seizure activity. She reports mild exertional shortness of breath and a nonproductive cough for approximately three days.
Past Medical History
- Hashimoto thyroiditis diagnosed 8 years ago
- Primary hypothyroidism
- Hyperlipidemia
- Chronic constipation
- Obesity
- No known adrenal insufficiency
- No known heart failure
Family History
- Mother — hypothyroidism
- Father — hypertension and coronary artery disease
- No known family history of adrenal disease
Social History
- Lives with adult daughter
- Recently unemployed
- Denies tobacco use
- Occasional alcohol use
- Denies recreational drug use
- Reports recent difficulty maintaining prescription coverage
Allergies
Sulfonamide antibiotics — rash
Review of Systems
Constitutional: Severe fatigue, increased sleep, cold intolerance, decreased activity tolerance, decreased appetite, and recent weight gain.
Neurologic: Slowed thinking, delayed responses, generalized weakness, and increasing somnolence. Denies seizure activity or focal weakness.
Cardiovascular: Reduced activity tolerance. Denies chest pain, palpitations, or syncope.
Respiratory: Mild exertional dyspnea and nonproductive cough.
Gastrointestinal: Constipation and decreased appetite. Denies vomiting or diarrhea.
Integumentary: Dry, coarse skin and increasing facial puffiness.
Endocrine: Marked cold intolerance, fatigue, and prolonged inconsistent thyroid medication use.
Physical Examination
General: Patient appears fatigued and mildly somnolent. Awakens to voice and answers questions appropriately, but responses are delayed.
Neurologic: Oriented to person, place, and situation. Speech is slowed. No focal neurologic deficits identified. Delayed relaxation phase of deep tendon reflexes noted.
Cardiovascular: Regular rhythm with bradycardia. Peripheral pulses palpable but mildly diminished. Mild bilateral nonpitting ankle edema present.
Respiratory: Respirations mildly shallow but nonlabored. Breath sounds diminished at bilateral bases with faint right lower-lobe crackles.
Gastrointestinal: Abdomen soft and nondistended. Bowel sounds hypoactive.
Skin: Skin cool, pale, dry, and coarse. Mild facial and periorbital puffiness present.
Labs
Initial laboratory findings demonstrate sodium 129 mEq/L and glucose 66 mg/dL. Thyroid studies reveal markedly elevated TSH and severely reduced free T4. Additional chemistry studies, serum cortisol, CBC, lactate, and blood cultures have been obtained.
Diagnostics
12-lead ECG demonstrates sinus bradycardia with low-voltage QRS complexes. Portable chest x-ray has been obtained because of cough, exertional dyspnea, diminished basal breath sounds, and right lower-lobe crackles. Final radiology interpretation is pending.
Assessment
Severe symptomatic primary hypothyroidism likely related to prolonged levothyroxine nonadherence. Hypothermia, bradycardia, hyponatremia, hypoglycemia, and altered alertness raise concern for progression toward severe decompensated hypothyroidism.
Possible respiratory infection may represent a precipitating stressor. Differential considerations include adrenal insufficiency, infection-related encephalopathy, and other metabolic causes of altered alertness.
Plan
- Continuous cardiac monitoring and pulse oximetry
- Establish peripheral IV access
- Obtain TSH and free T4
- Obtain CBC, CMP, magnesium, serum glucose, lactate, and serum cortisol
- Obtain blood cultures ×2 from separate sites
- Obtain 12-lead ECG
- Obtain portable chest x-ray
- Begin cautious isotonic IV fluid administration
- Initiate passive warming with warm blankets
- Perform frequent neurologic and respiratory reassessment
- Maintain fall precautions and assist with ambulation
- Request endocrinology consultation
- Escalate level of care for worsening mental status, hypotension, hypoventilation, hypoxemia, or progressive bradycardia
Provider Information
Dr. Zoe Langston, MD
Emergency Medicine
Patient arrived to the emergency department via wheelchair accompanied by adult daughter. Patient appears lethargic but awakens to verbal stimulation and is oriented to person, place, and situation. Responses are appropriate but delayed. Patient states, “Everything feels slow and I am freezing.”
Skin cool, pale, dry, and coarse to touch with mild facial and periorbital puffiness. Heart rhythm sinus bradycardia on bedside monitor with rate ranging 46–50 bpm. Patient denies chest pain or palpitations.
Respirations mildly shallow but nonlabored at rest. Breath sounds diminished at bilateral bases with faint crackles auscultated at the right posterior lung base. Oxygen saturation remains 94% on room air.
Abdomen soft and nondistended with hypoactive bowel sounds. Patient reports last bowel movement approximately four days ago.
Bilateral peripheral IV catheters inserted. Both IV sites remain clean, dry, and intact without redness, swelling, infiltration, or phlebitis.
Continuous cardiac monitoring and pulse oximetry initiated. Warm blankets applied for passive warming. Fall precautions initiated and patient instructed not to ambulate without staff assistance.
Daughter confirms patient has taken levothyroxine inconsistently for approximately two months following difficulty obtaining the medication.
Dr. Langston notified of temperature 95.7°F, heart rate 48 bpm, delayed responses, sodium 129 mEq/L, glucose 66 mg/dL, and increasing somnolence. Patient remains under frequent neurologic, respiratory, and hemodynamic reassessment.
Endocrinology
Endocrinology consultation has been requested because of severe symptomatic hypothyroidism with concern for acute clinical decompensation.
Formal endocrinology consultation note has not yet been documented at this timestamp.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Monitoring | Continuous cardiac monitoring and continuous pulse oximetry | Stat | Dr. Zoe Langston, MD | Active | Monitor for worsening bradycardia, dysrhythmia, hypoxemia, or hemodynamic deterioration. |
| IV Access | Insert two peripheral IV catheters | Stat | Dr. Zoe Langston, MD | Completed | Maintain patent access for fluids and emergency medication administration. |
| IV Fluid | 0.9% sodium chloride IV at 75 mL/hr continuous | Routine | Dr. Zoe Langston, MD | Active | Cautious volume replacement. Monitor blood pressure, lung sounds, sodium, intake/output, and signs of fluid overload. |
| Laboratory | TSH and free T4 once | Stat | Dr. Zoe Langston, MD | Completed | Evaluate thyroid function and severity of hypothyroidism. |
| Laboratory | CBC, CMP, magnesium, serum glucose, lactate, and serum cortisol once | Stat | Dr. Zoe Langston, MD | In Progress | Evaluate metabolic abnormalities, renal status, infection, and possible adrenal insufficiency. |
| Laboratory | Blood cultures ×2 from separate sites | Stat | Dr. Zoe Langston, MD | In Progress | Obtain before antimicrobial therapy if possible. Evaluate possible infectious precipitant. |
| Diagnostic | 12-lead ECG once | Stat | Dr. Zoe Langston, MD | Completed | Evaluate bradycardia and cardiac conduction. |
| Imaging | Portable chest x-ray | Stat | Dr. Zoe Langston, MD | In Progress | Evaluate cough, exertional dyspnea, diminished basal breath sounds, and right lower-lobe crackles. |
| Nursing | Passive warming with warm blankets | Routine | Dr. Zoe Langston, MD | Active | Monitor temperature. Avoid aggressive peripheral rewarming. |
| Nursing | Neurologic assessment every hour | Urgent | Dr. Zoe Langston, MD | Active | Notify provider for decreased responsiveness, worsening orientation, or additional neurologic decline. |
| Safety | Fall precautions and assist with ambulation | Routine | Dr. Zoe Langston, MD | Active | Generalized weakness, slowed responses, and near-fall prior to arrival. |
| Consult | Endocrinology consultation | Urgent | Dr. Zoe Langston, MD | Requested | Severe symptomatic hypothyroidism with concern for acute decompensation. |
| Vital Sign | 0815 | Reference Range |
|---|---|---|
| Temperature | 95.7°F / 35.4°C | 97–99°F / 36.1–37.2°C |
| Heart Rate | 48 bpm | 60–100 bpm |
| Respiratory Rate | 12 breaths/min | 12–20 breaths/min |
| Blood Pressure | 102/64 mmHg | <120/<80 mmHg |
| Oxygen Saturation | 94% on room air | 95–100% |
| Pain | 0/10 | Subjective scale 0–10 |
| Lab Test | 0815 Result | Reference Range |
|---|---|---|
| TSH | 78.6 mIU/L | 0.4–4.0 mIU/L |
| Free T4 | 0.21 ng/dL | 0.8–1.8 ng/dL |
| Sodium | 129 mEq/L | 135–145 mEq/L |
| Potassium | 4.1 mEq/L | 3.5–5.0 mEq/L |
| Glucose | 66 mg/dL | 70–100 mg/dL |
| BUN | 18 mg/dL | 10–20 mg/dL |
| Creatinine | 1.1 mg/dL | 0.6–1.2 mg/dL |
| Magnesium | 1.8 mg/dL | 1.3–2.1 mg/dL |
| WBC | 10,800 cells/mm³ | 5,000–11,000 cells/mm³ |
| Hemoglobin | 12.1 g/dL | Female: 12–15 g/dL |
| Lactate | 1.7 mmol/L | 0.5–2.2 mmol/L |
| Serum Cortisol | Pending | Interpretation varies by collection time |
- 12-Lead ECG — Completed: Sinus bradycardia at approximately 47 bpm with low-voltage QRS complexes. No acute ST-segment elevation or significant ventricular dysrhythmia identified.
- Portable Chest X-ray — In Progress: Imaging obtained at bedside because of cough, exertional dyspnea, diminished basal breath sounds, and right lower-lobe crackles. Final radiology interpretation pending.
- Thyroid Function Testing — Completed: TSH 78.6 mIU/L and free T4 0.21 ng/dL.
- Blood Cultures — Pending: Two sets obtained from separate sites to evaluate for a possible infectious precipitating factor.
- Continuous cardiac monitoring and pulse oximetry initiated.
- Two peripheral IV catheters established.
- Passive warming initiated with warm blankets.
- Fall precautions initiated because of weakness, slowed responses, and reported near-fall.
- Endocrinology consultation requested.
- Family confirmed prolonged inconsistent levothyroxine use.
- Dr. Langston notified of hypothermia, bradycardia, hyponatremia, low glucose, and increasing somnolence.
- Patient remains under frequent neurologic, respiratory, and cardiovascular reassessment due to concern for further clinical deterioration.
Review the complete timestamp before answering both questions.
The most concerning findings are the combination of increasing somnolence, hypothermia, bradycardia, hyponatremia, low glucose, and severely reduced free T4. Chronic hypothyroidism can cause fatigue, constipation, dry skin, weight changes, and cold intolerance, but altered mental status and significant physiologic slowing suggest worsening multisystem involvement.
Her temperature of 95.7°F and heart rate of 48 bpm demonstrate significant slowing of metabolic and cardiovascular function. Sodium of 129 mEq/L and glucose of 66 mg/dL add evidence of systemic dysfunction. Together, these findings increase concern for progression toward severe decompensated hypothyroidism and possible myxedema coma.
Priority nursing assessment should focus on airway and ventilation, oxygenation, neurologic status, cardiovascular status, temperature, and glucose. Continuous cardiac and pulse oximetry monitoring are important because severe hypothyroidism can lead to progressive bradycardia, decreased cardiac output, hypotension, hypoventilation, and worsening oxygenation.
Immediate escalation is warranted if Marissa becomes increasingly difficult to arouse, develops a decreasing respiratory rate or more shallow ventilation, worsening hypotension, progressive bradycardia, falling oxygen saturation, or further temperature decline. These findings would indicate worsening systemic decompensation and could require ICU-level monitoring, respiratory support, and more aggressive thyroid replacement and treatment of a precipitating cause.
Several hours after arrival, Marissa becomes increasingly difficult to arouse with worsening hypothermia, bradycardia, hypotension, hypoventilation, hypoxemia, hyponatremia, and hypoglycemia. Chest imaging also reveals a right lower-lobe infiltrate, increasing concern for pneumonia as a precipitating stressor and progression to severe decompensated hypothyroidism consistent with suspected myxedema coma.
Chief Concern
Worsening somnolence, hypothermia, bradycardia, hypotension, hypoventilation, and hypoxemia in the setting of severe untreated hypothyroidism.
Interval History
Marissa has demonstrated progressive decline since the initial emergency department assessment. She is now significantly more somnolent and requires repeated verbal stimulation and occasional tactile stimulation to remain awake during examination.
Nursing staff report progressively slower responses, continued complaints of feeling cold, and reduced spontaneous conversation. Her daughter states that Marissa appears substantially more difficult to awaken than she was earlier this morning.
Heart rate has decreased into the low 40s. Blood pressure has declined to 88/54 mmHg. Respiratory rate has decreased to 9 breaths/min with shallow respirations. Oxygen saturation decreased to 90% on room air and improved to 95% after application of 2 L/min oxygen by nasal cannula.
Repeat serum glucose is 61 mg/dL and sodium has declined to 126 mEq/L. Portable chest x-ray now demonstrates a focal right lower-lobe airspace opacity concerning for pneumonia.
Review of Systems
Review is limited by increasing somnolence. Patient endorses severe fatigue and generalized weakness when awake. Continues to report feeling extremely cold. Denies chest pain when aroused. Mild cough persists.
Physical Examination
General: Acutely ill-appearing woman with worsening somnolence. Requires repeated verbal stimulation to maintain attention.
Neurologic: Glasgow Coma Scale approximately 12. Opens eyes to verbal stimulation, speech is slow and limited, and patient follows simple commands with delay. No focal motor deficit identified.
Cardiovascular: Marked regular bradycardia. Heart rate approximately 41 bpm. Blood pressure 88/54 mmHg. Peripheral extremities cool with diminished peripheral pulses.
Respiratory: Respirations shallow at approximately 9/min. Oxygen saturation 90% on room air and 95% after application of 2 L/min nasal cannula. Breath sounds diminished at bases with persistent crackles over the right lower lung field.
Gastrointestinal: Abdomen soft and nondistended. Bowel sounds remain hypoactive.
Skin: Skin remains cool, pale, dry, and coarse. Facial and periorbital puffiness persists.
Labs
Repeat sodium decreased from 129 to 126 mEq/L. Serum glucose decreased from 66 to 61 mg/dL. WBC increased to 12,600 cells/mm³. Creatinine is 1.2 mg/dL. Serum cortisol resulted at 18.4 mcg/dL. Thyroid studies remain markedly abnormal with initial TSH 78.6 mIU/L and free T4 0.21 ng/dL.
Diagnostics
Portable chest x-ray demonstrates right lower-lobe airspace opacity concerning for pneumonia. ECG continues to demonstrate sinus bradycardia without acute ischemic changes. Blood cultures remain pending.
Assessment
Severe decompensated hypothyroidism with progressive altered mental status, hypothermia, bradycardia, hypotension, hypoventilation, hyponatremia, and hypoglycemia. Clinical picture is now highly concerning for myxedema coma.
Right lower-lobe pneumonia is the likely infectious precipitating stressor in addition to prolonged levothyroxine nonadherence.
Patient is at increased risk for progressive respiratory failure, cardiovascular collapse, worsening encephalopathy, severe electrolyte disturbance, and further metabolic deterioration.
Plan
- Transfer patient to intensive care unit for continuous hemodynamic and respiratory monitoring.
- Administer levothyroxine 200 mcg IV once as initial loading dose.
- Administer hydrocortisone 100 mg IV every 8 hours while adrenal insufficiency is being excluded and during acute decompensation.
- Administer dextrose for current hypoglycemia and repeat bedside glucose after treatment.
- Begin ceftriaxone and azithromycin for suspected community-acquired pneumonia.
- Continue supplemental oxygen and titrate to maintain adequate oxygenation.
- Continue cautious isotonic IV fluids with close pulmonary and hemodynamic assessment.
- Continue passive warming. Avoid aggressive peripheral rewarming.
- Repeat BMP and glucose every 4 hours.
- Continue hourly neurologic assessments.
- Closely monitor respiratory rate, depth, oxygenation, and ability to protect airway.
- Prepare for advanced airway management if mental status or ventilation continues to deteriorate.
- Endocrinology to continue management recommendations.
Provider Information
Dr. Zoe Langston, MD
Emergency Medicine
Patient noted to have increasing lethargy compared with initial assessment. Patient now requires repeated verbal stimulation to open eyes and maintain attention. Responses remain appropriate when awake but are significantly delayed. Patient follows simple commands slowly.
Current Glasgow Coma Scale approximately 12. No unilateral weakness, facial asymmetry, or other focal neurologic deficit observed.
Cardiac monitor demonstrates sinus bradycardia with heart rate 39–43 bpm. Current blood pressure 88/54 mmHg. Extremities remain cool and peripheral pulses are decreased but palpable.
Respiratory rate decreased to 9 breaths/min with shallow respirations. Oxygen saturation noted at 90% on room air. Patient placed on 2 L/min oxygen by nasal cannula with saturation improving to 95%. Right posterior lower-lobe crackles remain present.
Temperature 94.8°F / 34.9°C. Warm blankets remain in place for passive warming.
Bedside glucose resulted at 61 mg/dL. Dr. Langston notified immediately. IV dextrose administered per new provider order with repeat glucose scheduled following treatment.
Repeat laboratory results demonstrate sodium 126 mEq/L and WBC 12,600 cells/mm³. Portable chest x-ray result reviewed and reports right lower-lobe opacity concerning for pneumonia.
Ceftriaxone and azithromycin initiated per order after blood cultures had already been obtained. Hydrocortisone administered and IV levothyroxine prepared and administered per provider order.
Daughter updated regarding worsening condition and planned transfer to intensive care. ICU handoff completed using SBAR. Patient transported to ICU Room 304 on cardiac monitor and supplemental oxygen with RN accompaniment.
Consultant
Dr. Fatima Almasi, NP
Endocrinology
Reason for Consultation
Severe hypothyroidism with progressive hypothermia, bradycardia, altered mental status, hypotension, hypoventilation, hyponatremia, and hypoglycemia.
Impression
Clinical presentation is consistent with severe decompensated hypothyroidism and is highly concerning for myxedema coma in the setting of prolonged levothyroxine interruption. Right lower-lobe pneumonia likely contributed to acute deterioration.
Recommendations
- Levothyroxine 200 mcg IV loading dose now.
- Continue IV thyroid hormone replacement after loading dose with dose adjusted according to clinical response and follow-up thyroid studies.
- Hydrocortisone 100 mg IV every 8 hours during the initial acute period while adrenal insufficiency is being excluded.
- Treat identified precipitating infection.
- Monitor glucose and electrolytes closely.
- Avoid rapid correction of sodium.
- Continue passive warming rather than aggressive peripheral heating.
- ICU monitoring recommended because of worsening mental status, hypoventilation, hypotension, and bradycardia.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Monitoring | Continuous cardiac monitoring and continuous pulse oximetry | Stat | Dr. Zoe Langston, MD | Active | Continued due to worsening bradycardia, hypotension, and hypoxemia. |
| IV Access | Maintain two patent peripheral IV catheters | Routine | Dr. Zoe Langston, MD | Active | Required for IV thyroid hormone, corticosteroid, dextrose, fluids, and antibiotics. |
| IV Fluid | 0.9% sodium chloride IV at 75 mL/hr continuous | Routine | Dr. Zoe Langston, MD | Active | Continue cautiously. Monitor blood pressure, respiratory status, sodium, lung sounds, and signs of fluid overload. |
| Nursing | Passive warming with warm blankets | Routine | Dr. Zoe Langston, MD | Active | Continue gradual passive rewarming. Avoid aggressive peripheral heat. |
| Neurologic | Neurologic assessment every 1 hour | Urgent | Dr. Zoe Langston, MD | Active | Notify provider immediately for further decrease in responsiveness or inability to protect airway. |
| Safety | Fall precautions; bedrest with assisted activity only | Routine | Dr. Zoe Langston, MD | Active | Increased somnolence and generalized weakness. |
| Level of Care | Transfer to Intensive Care Unit | Stat | Dr. Zoe Langston, MD | Completed | ICU Room 304. Requires continuous hemodynamic, neurologic, and respiratory monitoring. |
| Medication | Levothyroxine 200 mcg IV once | Stat | Dr. Fatima Almasi, NP | Administered | Initial IV loading dose for severe decompensated hypothyroidism. |
| Medication | Hydrocortisone 100 mg IV every 8 hours | Stat | Dr. Fatima Almasi, NP | Active | Empiric stress-dose corticosteroid during acute decompensation while adrenal insufficiency is evaluated. |
| Medication | Dextrose 50% 25 g IV once | Stat | Dr. Zoe Langston, MD | Administered | Indication: glucose 61 mg/dL with altered mental status. Repeat bedside glucose after administration. |
| Medication | Ceftriaxone 1 g IV every 24 hours | Urgent | Dr. Zoe Langston, MD | Active | Empiric treatment for suspected community-acquired pneumonia. |
| Medication | Azithromycin 500 mg IV every 24 hours | Urgent | Dr. Zoe Langston, MD | Active | Additional coverage for suspected community-acquired pneumonia. |
| Respiratory | Oxygen 2 L/min by nasal cannula; titrate to maintain SpO₂ ≥ 94% | Stat | Dr. Zoe Langston, MD | Active | Monitor respiratory rate, depth, work of breathing, and mental status closely. |
| Laboratory | Basic metabolic panel every 4 hours | Urgent | Dr. Zoe Langston, MD | Active | Trend sodium, potassium, glucose, renal function, and other metabolic changes. |
| Laboratory | Bedside glucose every 4 hours and PRN for change in mental status | Urgent | Dr. Zoe Langston, MD | Active | Reassess following dextrose administration. |
| Respiratory | Notify provider for respiratory rate < 8/min, worsening hypoxemia, inability to protect airway, or increasing hypercapnia concern | Stat Parameters | Dr. Zoe Langston, MD | Active | Prepare for advanced airway management if respiratory function deteriorates. |
| Vital Sign | 0815 | 1245 | Reference Range |
|---|---|---|---|
| Temperature | 95.7°F / 35.4°C | 94.8°F / 34.9°C | 97–99°F / 36.1–37.2°C |
| Heart Rate | 48 bpm | 41 bpm | 60–100 bpm |
| Respiratory Rate | 12 breaths/min | 9 breaths/min | 12–20 breaths/min |
| Blood Pressure | 102/64 mmHg | 88/54 mmHg | <120/<80 mmHg |
| Oxygen Saturation | 94% on room air | 90% room air; 95% on 2 L NC | 95–100% |
| Pain | 0/10 | 0/10 | Subjective scale 0–10 |
| Glasgow Coma Scale | Approximately 14 | Approximately 12 | 15 |
| Lab Test | 0815 | 1245 | Reference Range |
|---|---|---|---|
| TSH | 78.6 mIU/L | 78.6 mIU/L | 0.4–4.0 mIU/L |
| Free T4 | 0.21 ng/dL | 0.21 ng/dL | 0.8–1.8 ng/dL |
| Sodium | 129 mEq/L | 126 mEq/L | 135–145 mEq/L |
| Potassium | 4.1 mEq/L | 4.0 mEq/L | 3.5–5.0 mEq/L |
| Glucose | 66 mg/dL | 61 mg/dL | 70–100 mg/dL |
| BUN | 18 mg/dL | 20 mg/dL | 10–20 mg/dL |
| Creatinine | 1.1 mg/dL | 1.2 mg/dL | 0.6–1.2 mg/dL |
| Magnesium | 1.8 mg/dL | 1.8 mg/dL | 1.3–2.1 mg/dL |
| WBC | 10,800 cells/mm³ | 12,600 cells/mm³ | 5,000–11,000 cells/mm³ |
| Hemoglobin | 12.1 g/dL | 11.9 g/dL | Female: 12–15 g/dL |
| Lactate | 1.7 mmol/L | 1.9 mmol/L | 0.5–2.2 mmol/L |
| Serum Cortisol | Pending | 18.4 mcg/dL | Interpretation depends on collection time and clinical context |
- Portable Chest X-ray — Final: Focal right lower-lobe airspace opacity concerning for pneumonia. Mild bibasilar atelectatic change also noted. No large pleural effusion or pneumothorax identified.
- 12-Lead ECG — Previously Completed: Sinus bradycardia with low-voltage QRS complexes. Heart rate remains in the low 40s on continuous monitoring. No acute ST-segment elevation or sustained ventricular dysrhythmia.
- Thyroid Function Testing — Completed: TSH remains markedly elevated at 78.6 mIU/L with free T4 severely reduced at 0.21 ng/dL.
- Blood Cultures — Pending: Two sets previously collected from separate sites. No final growth results available at this timestamp.
- Serum Cortisol — Resulted: Cortisol 18.4 mcg/dL. Result reviewed in clinical context while empiric stress-dose hydrocortisone continues during acute decompensation.
- Patient became increasingly difficult to arouse with Glasgow Coma Scale decreasing to approximately 12.
- Temperature declined from 95.7°F to 94.8°F.
- Heart rate decreased from 48 bpm to approximately 41 bpm.
- Blood pressure declined from 102/64 mmHg to 88/54 mmHg.
- Respiratory rate decreased from 12 to 9 breaths/min with shallow respirations.
- Oxygen saturation decreased to 90% on room air and improved to 95% with 2 L/min nasal cannula.
- Repeat glucose decreased to 61 mg/dL. IV dextrose administered.
- Sodium declined from 129 to 126 mEq/L.
- Portable chest x-ray demonstrated a right lower-lobe infiltrate concerning for pneumonia.
- Ceftriaxone and azithromycin initiated after previously obtained blood cultures.
- Hydrocortisone and IV levothyroxine initiated for suspected myxedema coma.
- Endocrinology completed consultation and agreed with escalation of thyroid replacement therapy.
- Patient transferred from the emergency department to ICU Room 304 for higher-level monitoring and care.
- Advanced airway equipment available at bedside because of declining respiratory rate and mental status.
Use the trend data from both timestamps before answering.
The strongest evidence of worsening decompensation is the simultaneous decline in neurologic, respiratory, cardiovascular, metabolic, and thermoregulatory function. Marissa is more difficult to arouse, her GCS has decreased, her temperature has fallen from 95.7°F to 94.8°F, her heart rate has decreased from 48 to 41 bpm, and her blood pressure has fallen from 102/64 to 88/54 mmHg.
Her respiratory rate has also decreased from 12 to 9 breaths/min with new hypoxemia requiring supplemental oxygen. In addition, sodium has declined from 129 to 126 mEq/L and glucose has decreased from 66 to 61 mg/dL. The progression across multiple organ systems rather than one isolated abnormal finding is what makes this pattern especially concerning for myxedema coma.
The immediate priority is assessment and support of airway and ventilation. The nurse should evaluate respiratory rate and depth, work of breathing, oxygen saturation, breath sounds, mental status, and the patient's ability to maintain and protect her airway while continuing supplemental oxygen and continuous monitoring.
A further decrease in responsiveness combined with progressively slower or more shallow respirations would be especially concerning because a patient who cannot maintain ventilation or protect the airway may require endotracheal intubation and mechanical ventilation. Falling oxygen saturation despite supplemental oxygen, respiratory rate below ordered parameters, evidence of carbon dioxide retention, or inability to respond to stimulation would all require immediate escalation. Oxygen alone can improve saturation but does not correct inadequate ventilation.
Following ICU transfer, IV thyroid replacement, corticosteroid therapy, treatment of hypoglycemia, supplemental oxygen, cautious IV fluids, and antibiotics for pneumonia, Marissa demonstrates improving mental status, temperature, heart rate, blood pressure, oxygenation, sodium, and glucose. She remains under close monitoring because full endocrine and physiologic recovery is still ongoing.
Chief Concern
Follow-up of severe decompensated hypothyroidism with suspected myxedema coma and right lower-lobe pneumonia after initial ICU stabilization.
Interval History
Marissa has demonstrated gradual improvement overnight following IV levothyroxine, hydrocortisone, correction of hypoglycemia, cautious IV fluid administration, passive warming, supplemental oxygen, and antimicrobial therapy.
She is now awake spontaneously and able to participate in conversation without repeated stimulation. Speech remains mildly slowed, but responses are appropriate and substantially faster than during the prior assessment.
Temperature has increased to 97.1°F. Heart rate has improved to 58 bpm and blood pressure is now 108/68 mmHg. Respiratory rate is 15 breaths/min with improved depth. Oxygen saturation is 97% on 1 L/min nasal cannula.
Repeat metabolic studies show sodium 132 mEq/L and glucose 91 mg/dL. Free T4 has increased from 0.21 to 0.46 ng/dL. TSH remains markedly elevated at 72.9 mIU/L, which is expected to improve more slowly.
Review of Systems
Constitutional: Fatigue persists but is improved. Patient reports feeling warmer and more alert.
Neurologic: Denies headache, dizziness, or focal weakness. Reports thinking feels clearer.
Cardiovascular: Denies chest pain or palpitations.
Respiratory: Mild nonproductive cough persists. Shortness of breath improved.
Gastrointestinal: Appetite beginning to improve. Constipation remains present.
Endocrine: Cold intolerance improved compared with previous day.
Physical Examination
General: Awake, calm, and cooperative. No acute distress.
Neurologic: Alert and oriented ×4. Speech mildly slowed but clear. Follows commands appropriately. No focal neurologic deficits identified.
Cardiovascular: Regular rhythm with improving bradycardia. Heart rate approximately 58 bpm. Blood pressure 108/68 mmHg. Peripheral pulses improved.
Respiratory: Respirations even and nonlabored at 15 breaths/min. Oxygen saturation 97% on 1 L/min nasal cannula. Breath sounds remain mildly diminished at the right base with residual crackles.
Gastrointestinal: Abdomen soft, nondistended, and nontender. Bowel sounds remain mildly hypoactive.
Skin: Skin warmer than previous assessment. Dryness remains present. Facial puffiness is reduced.
Labs
Sodium improved to 132 mEq/L and glucose is now 91 mg/dL. Creatinine improved to 1.0 mg/dL. WBC decreased to 11,400 cells/mm³. Free T4 increased to 0.46 ng/dL while TSH remains elevated at 72.9 mIU/L.
Diagnostics
Continuous telemetry demonstrates sinus bradycardia with improving heart rate and no sustained dysrhythmia. Chest imaging remains consistent with right lower-lobe pneumonia. Blood cultures show no growth to date.
Assessment
Severe decompensated hypothyroidism with suspected myxedema coma, now showing early clinical improvement following IV thyroid hormone replacement and supportive care.
Associated hypothermia, hypotension, hypoventilation, hypoglycemia, hyponatremia, and encephalopathy are improving.
Right lower-lobe pneumonia remains the likely precipitating infectious stressor and is responding clinically to antimicrobial therapy.
Plan
- Continue ICU monitoring at this time.
- Continue levothyroxine 75 mcg IV daily.
- Continue hydrocortisone 100 mg IV every 8 hours today; reassess continued need with endocrinology.
- Continue ceftriaxone and azithromycin for right lower-lobe pneumonia.
- Wean supplemental oxygen as tolerated.
- Continue cautious IV fluids and reassess volume status regularly.
- Continue BMP and bedside glucose monitoring.
- Repeat free T4 and TSH per endocrinology recommendations.
- Advance activity gradually with nursing assistance.
- Continue fall precautions while weakness persists.
- Begin medication-access and adherence education before discharge.
- Case management to assist with medication coverage and outpatient follow-up.
- Consider transfer to step-down or medical unit if neurologic, cardiovascular, and respiratory improvement continues.
Provider Information
Dr. Nadia Wells, MD
Intensive Care Medicine
Patient awake spontaneously on morning assessment and able to maintain conversation without repeated verbal stimulation. Alert and oriented to person, place, time, and situation. Speech remains mildly slowed but responses are clear and appropriate.
Patient states, “I feel much more awake today.” Denies chest pain, palpitations, or dizziness. Reports continued fatigue but states cold sensation has significantly improved.
Cardiac monitor demonstrates sinus rhythm with rate 56–60 bpm. Blood pressure currently 108/68 mmHg. Peripheral pulses palpable and stronger than previous shift.
Respirations even and nonlabored at 15 breaths/min. Oxygen saturation 97% on 1 L/min nasal cannula. Breath sounds remain diminished at the right base with mild residual crackles.
Temperature 97.1°F / 36.2°C. Passive warming measures no longer required continuously. Warm blanket remains available for comfort.
Bedside glucose 91 mg/dL. No recurrent symptoms of hypoglycemia noted. Repeat sodium 132 mEq/L.
Bilateral peripheral IV sites remain clean, dry, and intact without signs of infiltration or phlebitis. IV fluids infusing per order.
Patient assisted to sit at bedside with two-person standby assistance. Mild generalized weakness remains, but patient tolerated activity without dizziness, hypotension, or oxygen desaturation.
Patient and daughter educated regarding importance of consistent levothyroxine use, taking medication as prescribed, and notifying the healthcare team if medication cost or prescription access becomes a barrier.
Fall precautions remain in place. Patient instructed to call for assistance before getting out of bed.
Consultant
Dr. Fatima Almasi, NP
Endocrinology
Interval Assessment
Patient demonstrates meaningful clinical improvement following IV levothyroxine loading dose and supportive management. Mental status, temperature, blood pressure, respiratory rate, glucose, and sodium have all improved.
Thyroid Function
Free T4 increased from 0.21 ng/dL to 0.46 ng/dL. TSH remains elevated at 72.9 mIU/L.
TSH is expected to decline more slowly than free T4 and clinical symptoms; therefore, current clinical improvement and free T4 trend are more useful for evaluating the immediate treatment response.
Recommendations
- Continue levothyroxine 75 mcg IV daily.
- Continue close clinical monitoring.
- Repeat free T4 according to clinical response and treatment plan.
- Continue hydrocortisone during the acute period and reassess need as clinical stability improves.
- Continue treatment of pneumonia.
- Transition back to oral levothyroxine when patient is clinically stable and reliably tolerating oral medications.
- Provide detailed medication-adherence teaching before discharge.
- Address prescription-access barriers before discharge to reduce risk of recurrence.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Monitoring | Continuous cardiac monitoring and pulse oximetry | Routine | Dr. Nadia Wells, MD | Active | Continue while patient remains in ICU and while bradycardia and oxygen needs are resolving. |
| IV Access | Maintain peripheral IV access | Routine | Dr. Nadia Wells, MD | Active | Required for IV levothyroxine, corticosteroid, antibiotics, and fluids. |
| IV Fluid | 0.9% sodium chloride IV at 50 mL/hr | Routine | Dr. Nadia Wells, MD | Active | Rate reduced as blood pressure, renal function, and oral intake improve. Continue monitoring volume status. |
| Medication | Levothyroxine 75 mcg IV daily | Routine | Dr. Fatima Almasi, NP | Active | Maintenance IV thyroid replacement following initial loading dose. |
| Medication | Hydrocortisone 100 mg IV every 8 hours | Routine | Dr. Fatima Almasi, NP | Active | Continue during acute stabilization. Reassess ongoing need with endocrinology. |
| Medication | Ceftriaxone 1 g IV every 24 hours | Routine | Dr. Zoe Langston, MD | Active | Continue for treatment of right lower-lobe pneumonia. |
| Medication | Azithromycin 500 mg IV every 24 hours | Routine | Dr. Zoe Langston, MD | Active | Continue as part of treatment for suspected community-acquired pneumonia. |
| Respiratory | Oxygen 1 L/min by nasal cannula; wean as tolerated | Routine | Dr. Nadia Wells, MD | Active | Maintain adequate oxygenation and reassess on room air as tolerated. |
| Laboratory | Basic metabolic panel every 8 hours | Routine | Dr. Nadia Wells, MD | Active | Frequency reduced as sodium and glucose stabilize. |
| Laboratory | Bedside glucose every 6 hours and PRN | Routine | Dr. Nadia Wells, MD | Active | Continue monitoring for recurrent hypoglycemia. |
| Laboratory | Repeat free T4 and TSH per endocrinology | Routine | Dr. Fatima Almasi, NP | Active | Trend response to thyroid hormone replacement. |
| Neurologic | Neurologic assessment every 2 hours | Routine | Dr. Nadia Wells, MD | Active | Frequency reduced following improvement in mental status. |
| Safety | Fall precautions and assisted ambulation | Routine | Dr. Nadia Wells, MD | Active | Generalized weakness remains despite improvement in mental status. |
| Activity | Increase activity as tolerated with nursing assistance | Routine | Dr. Nadia Wells, MD | Active | Monitor blood pressure, heart rate, oxygen saturation, and symptoms with activity. |
| Consult | Case management consultation | Routine | Dr. Nadia Wells, MD | Requested | Assist with prescription coverage, medication access, and discharge planning. |
| Vital Sign | 0815 | 1245 | 0715 | Reference Range |
|---|---|---|---|---|
| Temperature | 95.7°F / 35.4°C | 94.8°F / 34.9°C | 97.1°F / 36.2°C | 97–99°F / 36.1–37.2°C |
| Heart Rate | 48 bpm | 41 bpm | 58 bpm | 60–100 bpm |
| Respiratory Rate | 12 breaths/min | 9 breaths/min | 15 breaths/min | 12–20 breaths/min |
| Blood Pressure | 102/64 mmHg | 88/54 mmHg | 108/68 mmHg | <120/<80 mmHg |
| Oxygen Saturation | 94% room air | 90% room air; 95% on 2 L NC | 97% on 1 L NC | 95–100% |
| Pain | 0/10 | 0/10 | 0/10 | Subjective scale 0–10 |
| Glasgow Coma Scale | Approximately 14 | Approximately 12 | 15 | 15 |
| Lab Test | 0815 | 1245 | 0715 | Reference Range |
|---|---|---|---|---|
| TSH | 78.6 mIU/L | 78.6 mIU/L | 72.9 mIU/L | 0.4–4.0 mIU/L |
| Free T4 | 0.21 ng/dL | 0.21 ng/dL | 0.46 ng/dL | 0.8–1.8 ng/dL |
| Sodium | 129 mEq/L | 126 mEq/L | 132 mEq/L | 135–145 mEq/L |
| Potassium | 4.1 mEq/L | 4.0 mEq/L | 4.2 mEq/L | 3.5–5.0 mEq/L |
| Glucose | 66 mg/dL | 61 mg/dL | 91 mg/dL | 70–100 mg/dL |
| BUN | 18 mg/dL | 20 mg/dL | 18 mg/dL | 10–20 mg/dL |
| Creatinine | 1.1 mg/dL | 1.2 mg/dL | 1.0 mg/dL | 0.6–1.2 mg/dL |
| Magnesium | 1.8 mg/dL | 1.8 mg/dL | 1.9 mg/dL | 1.3–2.1 mg/dL |
| WBC | 10,800 cells/mm³ | 12,600 cells/mm³ | 11,400 cells/mm³ | 5,000–11,000 cells/mm³ |
| Hemoglobin | 12.1 g/dL | 11.9 g/dL | 11.8 g/dL | Female: 12–15 g/dL |
| Lactate | 1.7 mmol/L | 1.9 mmol/L | 1.4 mmol/L | 0.5–2.2 mmol/L |
| Serum Cortisol | Pending | 18.4 mcg/dL | 18.4 mcg/dL | Interpret according to collection time and clinical context |
- Continuous Telemetry — Ongoing: Sinus rhythm with mild persistent bradycardia. Heart rate now generally 56–60 bpm. No sustained ventricular dysrhythmia identified.
- Portable Chest X-ray — Previously Completed: Right lower-lobe airspace opacity remains consistent with pneumonia. No pneumothorax or large pleural effusion.
- Thyroid Function Testing — Repeat: Free T4 improved to 0.46 ng/dL. TSH remains elevated at 72.9 mIU/L.
- Blood Cultures — Preliminary: No growth to date. Final culture results remain pending.
- Bedside Respiratory Assessment — Ongoing: Respiratory rate and depth improved. Patient is maintaining adequate oxygenation on reduced supplemental oxygen and has not required advanced airway support.
- Mental status improved from GCS approximately 12 to GCS 15.
- Patient now awake spontaneously and oriented ×4.
- Temperature improved from 94.8°F to 97.1°F.
- Heart rate improved from 41 bpm to 58 bpm.
- Blood pressure improved from 88/54 mmHg to 108/68 mmHg.
- Respiratory rate improved from 9 to 15 breaths/min.
- Supplemental oxygen decreased from 2 L/min to 1 L/min nasal cannula.
- Sodium improved from 126 to 132 mEq/L.
- Glucose improved from 61 to 91 mg/dL without recurrent hypoglycemia.
- Free T4 increased from 0.21 to 0.46 ng/dL.
- Patient tolerated sitting at bedside with assistance without hypotension or oxygen desaturation.
- No advanced airway intervention required.
- Medication-access education and discharge planning initiated with patient and daughter.
- Patient may be considered for transfer out of ICU if improvement continues.
Review the complete trend across all three timestamps before answering.
Marissa is showing improvement across several systems. Her mental status has improved to alert and oriented ×4, temperature has increased to 97.1°F, heart rate has risen to 58 bpm, blood pressure has improved to 108/68 mmHg, respiratory rate has normalized, and her oxygen requirement has decreased. Sodium and glucose have also improved, and free T4 has risen from 0.21 to 0.46 ng/dL.
TSH does not respond immediately to thyroid hormone replacement because pituitary feedback and normalization of the hypothalamic-pituitary- thyroid axis occur more slowly. During the acute phase, the patient's clinical status and the direction of the free T4 trend provide more useful information about immediate treatment response. A persistently elevated TSH at this stage does not mean treatment has failed.
The team must address the reason Marissa stopped taking levothyroxine consistently. Her medication interruption was related to difficulty obtaining the prescription after loss of employer-sponsored medication coverage, so education alone is not sufficient if the access problem remains.
Nursing, case management, pharmacy, and the medical team should confirm that she has an affordable and reliable way to obtain levothyroxine, understands how and when to take it, and knows not to ration or discontinue it without contacting a healthcare professional. She also needs outpatient endocrinology or primary care follow-up and repeat thyroid laboratory monitoring. Addressing the social and medication- access barrier is an important part of preventing recurrence.