I would be interested in any of your thoughts regarding a case that I had the other night.

A women in her mid 40's was brought in after being found minimally responsive by her husband at 11am. He checked her blood sugar which was 22, placed 2 glucose tablets into her mouth and called an ambulance. When the crew arrived her blood sugar was normal, however her mentation had not improved. She had last been seen by her husband at 8 am when she woke up to check her blood sugar and then went back to bed, which was not unusual for her. Her husband did not know whether she had eaten or taken her medication.

When she arrived in our department her GCS was 13 and her blood sugar 140 (it remained >100 during her 4 hour stay in our department). She would open her eyes to voice and follow simple commands, however she would not stay aroused without stimulation.

She has a history of DM, HTN, Grave's Disease (treated with radiation therapy), and sleep apnea. Her medications included insulin, oral hypoglycemics, synthroid and xanax (she had the appropriate number of pills left in the bottle after a recent refill).

On physical exam, her vitals were normal (including rectal temp) with the exception of her pulse ox which was in the low 90's. She had exophthalmos, which her husband stated had worsened recently, otherwise her HEENT exam was unremarkable. I did not palpate a goiter. Her heart, lung and abdominal exam were normal with the exception of obesity. She had no focal neurologic deficits noted. Only trace peripheral edema was noted.

Her electrolytes, BUN, creatinine, anion gap, osmolar gap and CBC were normal. Her blood gases revealed a normal pH and pCO2, however her pO2 was 71. Her drug screen was positive only for the benzodiazapenes. Her TSH was 43 with a T4 of 0.8.
Her head CT was normal.

Her respiratory status worsened while in the department and we intubated her. Her mental status improved only slightly. She was given an initial dose of Thyroxine in the department but I do not know whether or not this was continued in the ICU. Her mental status improved and she was extubated the following day.

The internist believes her mental status was secondary to her hypoglycemia. I have never seen anyone with such prolonged mental depression following the correction of hypoglycemia and believe she was in myxedema coma, however I've never seen this either. Does anyone have any thoughts?

Renee