Case Report
A 78-year-old woman with multiple medical comorbidities presented to the
emergency department (ED) at an academic medical center with one week of
progressive confusion and sleepiness. Her vital signs on admission were
normal. Examination revealed a somnolent elderly female, oriented only
to person. Additionally, a low-pitched coarse voice and delayed
relaxation of reflexes were present on examination.
When conducting the admission medication history, the medical intern and
senior resident accessed the list of the patient’s outpatient
medications from the health system’s electronic medical record (the
patient received most of her care at this hospital and its clinics) and
then interviewed the patient’s daughter, who managed her mother’s home
medications. Each of the patient’s fourteen medication was verified with
the patient’s daughter including the dose, timing, and indication. The
patient’s daughter was quite familiar with detailed information
regarding the patient’s medications even specific nuances such as the
importance of giving levothyroxine before breakfast.
Workup of the patient’s encephalopathy revealed a markedly elevated
thyroid stimulating hormone concentration (189 mU/L, normal: 0.4-4.2
mU/L). This finding was perplexing given a normal value one month prior
with no missed levothyroxine doses in the past month according to the
patient’s daughter. A free T4 of 0.4 mg/dL (normal 4.5-11.2 mg/dL)
confirmed severe, symptomatic hypothyroidism. The patient was promptly
treated with intravenous (IV) levothyroxine due to concerns of possible
compromised oral levothyroxine absorption. Further testing involving a
levothyroxine absorption test, requiring up to nine blood draws, as well
as brain imaging to evaluate for an intracranial etiology, was
considered to determine the underlying cause of the hypothyroidism in
the face of reported levothyroxine compliance. After several days of IV
levothyroxine and before initiating this intensive and costly workup, a
resident physician on the team asked the patient’s daughter to bring in
all her mother’s medications from home, including pill bottles and pill
organizers. To everyone’s surprise—none more so than the
daughter’s—levothyroxine was absent. A telephone call to the patient’s
outpatient pharmacy confirmed no levothyroxine had been dispensed for
the preceding month. The daughter, involved in the care of both her
medically complex mother and father, had not realized the levothyroxine
was missing from her mother’s medications. The patient’s home oral
levothyroxine was then reinitiated by the medical team, and she made a
complete recovery without relapse of symptoms.