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Myxedma crisis

Presented this talk at Grand Rounds at Virginia Mason on March 23rd 2018

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Myxedma crisis

  1. 1. Myxedema Crisis Travis Gerrard, MD
  2. 2. 73 year old male presents with SOB, cough, confusion, anasarca
  3. 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. 4. Diagnostics: Labs ● Troponin 0.16 ● BNP 1341 ● Glucose 62 ● Elevated AST/ALT ● Random cortisol 13
  5. 5. Diagnostics: Imaging ● CT chest ● CT/CTA head ● Transthoracic Echocardiogram
  6. 6. Day 5 First stool of hospital stay
  7. 7. Patient Issues ● Hypoxic respiratory failure ● Pneumonia ● NSTEMI ● Acute CHF ● CVA ● Hypoglycemia ● Constipation
  8. 8. 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
  9. 9. Assumption bias ● Taking for granted that something has already been done
  10. 10. Anchoring ● Focus on early signs/symptoms ● Tendency to regress toward the anchor ○ Ignore other information
  11. 11. Premature closure / Search satisfaction ● Accepting initial diagnosis ● Calling off search once reasonable explanation found
  12. 12. Availability Heuristic ● Recent / more common diagnosis are easily brought to mind
  13. 13. 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
  14. 14. 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
  15. 15. Questions?

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