A 75-year-old female is brought to the Emergency Department (ED) by emergency medical services (EMS) for altered mental status. Vital signs include BP 87/64, HR 55, T 92.6 rectal, RR 12, SpO2 95% on room air. She is oriented to person only with a GCS of 12. She is found to be bradycardic and her extremities are cool with bilateral non-pitting edema on both legs. Her husband is en route but currently unreachable for further history.

Background:
Decompensated hypothyroidism AKA Myxedema Coma is a diagnosis we must recognize early in the ED as delayed or missed diagnosis carries significant mortality and morbidity.

Unfortunately, it is incredibly easy to miss as it commonly presents with a constellation of nonspecific symptoms similar to many common ED chief complaints. Due to the thyroids varied affects, hypothyroidism can affect a vast array of organ systems.

Typically, a patient maintains homeostasis until a precipitating event induces decompensated hypothyroidism. Myxedema coma is most often seen in female elderly patients and tends to occur during the winter months.

Precipitating Events:
There are a wide variety of precipitating causes, listed in Table 1. Infection is one of the most common causes.

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