An interesting case of coma

1. INTERESTING CASE
PRESENTATION FROM M2 UNIT

2. • 44/F
• Kannur
• Unmarried
• c/o Altered sensorium – 1 day

3. • HOPC :
• A 44-year-old woman presented to the
emergency department after being found
unconscious in her home by her relatives , on
a fine morning . She lived alone , bystanders
were not aware of her past medical history .
• Relatives reportred that she was c/o tiredness
over past few weeks .

4. • No h/o fever , convulsion , vomiting/headache
, weakness of limbs , facial asymmetry ,
sedative/ narcotic abuse .

5. • Past History :
• h/o Total thyroidectomy 5 months ago .
• She had class iii toxic MNG and was on tab
carbimazole for 1 yr  surgery was done as
after having euthyroid state .
• Post surgery  tab Thyronorm
100micrograms OD , irregular follow up .

6. • She had send her relative to buy medicines .

7. • No H/O trauma, T2DM , S.HTN , CAD or other
significant past medical/ surgical history .

8. • Family hisory : Nil significant
• Personal history :
mixed diet , increased sleep over last few
months . Bowel/bladder normal . No addictions

9. On Examination
• PR - 54/min, which was regular and of normal
volume.
• BP - 100/62 mm Hg in a supine position, there
was no postural fall in blood pressure.
• RR- 18–20/min
• T- 94°F (axillary).

10. GENERAL EXAMINATION
• Unconscious
• Generalised puffiness , periorbital oedema
present .
• Extremeties cold with dry, scaly skin and non
pitting edema
• Transverse surgical scar on neck present .
• Pallor & Oedema present . No ICCL

12. SYSTEMIC EXAMINATION
• CNS :
GCS – E-2 ; M-4 ; V-3 = 9/15
Pupils – 4mm . Reactive to light
No neck stiffness
Plantar – Bilateral extensor
DTR – Absent
Fundus examination – wnl

13. • RS – AEBE , NVBS b/l
• CVS – S1S2 N ; no murmur
• P/A : soft ; no HSM

14. INVESTIGATIONS
CBC 
• Hb – 11.5gm%
• TC – 7.8
• PLT - 180
• ESR – 20 mm/hr

15. • P.smear– wnl
• RFT – Urea -24mg % , Creat – 0.9mg%.
• LFT -wnl
• RBS – 77mg%
• U R/E – wnl
• Troponin - < 0.02ng/ml

16. ABG
• pH - 7.486,
• pCO2 - 30.6 mmHg,
• pO2 - 36.4 mmHg,
• HCO3- 22.9 mM/L
• Oxygen saturation - 77%.

18. • ECG : sinus bradycardia ; low voltage complex .
• CXR – normal
• ECHO : wnl
• CT Brain : wnl

21. Summary ….

22. DIAGNOSIS
• Myxoedema Coma
• Euvolumic hyponatremia

23. Differential diagnosis ??
• Myxoedema coma
• Hypothermia
• Septic shock
• Psychiatric disorders , dementia , deppression
• changes in mental state secondary to other
medical conitions , drugs .
• Hypoglycemia
• Encephalitis , meningitis
• hepatic encephalopathy
• Cerebrovascular disease.

24. MYXOEDEMA COMA

26. • Common disorder of older age group .
• Women 8% > Men 2%
• Mortality rate > 50% without treatment .
>25% with treatment .

41. Thank you