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.