An 82-year-old woman found semiconscious at home has temperature 34.6°C, heart rate 44/min, dry skin, delayed relaxation of ankle jerks, and periorbital puffiness. Glucose is 58 mg/dL and sodium 126 mEq/L. Which pair of treatments should be started together in the emergency department?

• A IV triiodothyronine and fludrocortisone
• B Oral levothyroxine and IV dextrose alone
• C IV levothyroxine and IV hydrocortisone ✓
• D IV hydrocortisone and empirical antibiotics only

Explanation

This is myxedema coma: hypothermia, bradycardia, altered sensorium, hyponatraemia, and hypoglycaemia in severe hypothyroidism. Treatment is IV levothyroxine plus IV hydrocortisone, because coexisting adrenal insufficiency cannot be excluded before cortisol results return and thyroxine replacement alone can precipitate adrenal crisis. Oral levothyroxine is unreliable with impaired gut absorption in coma, and fludrocortisone adds nothing since mineralocorticoid function is usually preserved in pituitary rather than primary disease.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.