The correct answer is:

Myxedema

BONUS follow-up question:

Which of the physical findings is not consistent with the diagnosis of myxedema?

Hypothermia
Bradycardia
Large tongue
Normal deep tendon reflexes

The correct answer is:

Normal deep tendon reflexes

Key Point:

A poorly performed portion of the physical examination (or not performed at all) may lead to a mistaken diagnosis.

Explanation:

There can be little doubt that this patient has myxedema. Hypothermia, hypotension, bradycardia, slow breathing, the large tongue, abnormal mental status, puffy body appearance and a mature scar in the midline of the neck all point to this diagnosis.

It is highly unlikely that the patient has normal deep tendon reflexes. Patients with this degree of hypothyroidism almost always will demonstrate delay in the relaxation phase of the tendon reflexes.

Either the reflexes were not checked or the examiner failed to observe the abnormality.

In patients who are alert and oriented, the best way to demonstrate the delay is to have the patient kneel in a chair with the ankles pointing to the ceiling. After gently hyperextending the ankles, a tap with the reflex hammer will show a normal, brisk contraction but a very slow relaxation phase, usually about twice as long as the contraction phase.

Adrenal insufficiency, Alzheimer’s Disease, and medication induced delirium should be considered in the differential.

Adrenal insufficiency, severe enough to result in delirium, would be accompanied by signs of dehydration, not observed in this patient.

The patient could indeed have Alzheimer’s Disease but further consideration of this disease would await evidence of irreversible cognitive loss after treatment of the hypothyroidism.

Medication induced delirium must always be considered in elderly patients who present with confusion.

The plethora of findings of myxedema, like Alzheimer’s, would bring in the question of drug-induced delirium only if the patient failed to improve after thyroid replacement.

The value of clinical skills depends on whether the examiner performs the procedure properly (or performs it at all).

References:

Eishimy G, Correa R, Myxedema,  Stat Pearls (internet),  Stat Pearls Publishing, 2020-2019

Surks MI, Clinical manifestations of Hypothyroidism, Up To Date. Last Updated July 16, 2019, accessed March 10, 2020