A 37-year-old Woman with Altered Mental Status and Urinary Frequency
A 37-year-old woman presented to the emergency department (ED), brought in by her boyfriend, with the chief complaint of altered mental status. The patient was alert but agitated and refusing to answer questions regarding orientation. She would only state, “I don’t feel right,” “I want to get out of here,” and “I need to go to the bathroom to urinate.” Because of her inability to provide a history, the initial history was provided by her boyfriend.\nThe patient had been under stress lately due to the start of a new job that same day after 2 years of unemployment. The patient was last seen normal that morning, just prior to leaving for her job. Her boyfriend received a phone call from the patient in the afternoon, during which she seemed frightened, anxious, and unaware of her surroundings. The boyfriend subsequently brought the patient to the ED, because he was concerned about the patient’s behavior and was worried that she might have “taken more than 1 pill of lorazepam.”\nShe had no past medical, surgical, or psychiatric history, no known allergies, and no family history of illnesses. An outside physician had prescribed the patient lorazepam for “anxiety” 1 month prior, but she did not fill the prescription. There was also no history of recreational drug use.\nHer initial physical examination included the following vital signs: blood pressure 127/82 mmHg, heart rate 117 beats/min, respiratory rate 22 breaths/min, temperature 36.8°C, and oxygen saturation 100% on room air. She appeared frightened, did not make eye contact, and refused to answer questions. She continued to state, “I don’t feel right. I want to go home.” She intermittently attempted to climb over the railing of the gurney during the examination, alternating with being in a fetal position. Her pupils were both 5 mm in diameter, round, and reactive. Her mucous membranes were moist, and her neck was supple and without masses. Her lungs were clear to auscultation, and her heart was tachycardic without any murmurs, rubs, or gallops. Her abdomen was soft and nondistended. Her neurologic exam was limited due to her lack of cooperation. She could state her name but refused to answer any further questions about orientation. Her cranial nerves were grossly intact, she was moving all 4 extremities, and her gait was normal. Her extremities appeared normal with no edema. Her skin was warm and dry without evidence of trauma or a rash.\nThe results of her initial laboratory testing are listed in . The notable findings were a decreased CO2, accompanied by a primary respiratory alkalosis found on venous blood gas test. The electrocardiogram showed sinus tachycardia at a heart rate of 112 beats/min with normal intervals (including a QTc of 411) and no ST or T changes.\nDuring the initial work-up period, the patient was given 2 mg of lorazepam orally and 2 liters of intravenous normal saline. Even prior to receiving fluids, the patient was making frequent trips to the bathroom, where she produced variable amounts of urine. She had to urinate 6 times during an 8-hour ED stay. Her heart rate continued to rise to as fast as 140 beats/min. Her temperature eventually spiked to 38.2°C.\nBecause of the patient’s escalating heart rate, fever, and progressively worsening confusion, an infectious workup was pursued, which included a chest radiograph (CXR), urine analysis, and non-contrast head computed tomography (CT). Additionally, a lumbar puncture (LP) was performed. The CXR, non-contrast head CT, and LP were all normal. A urine toxicology screen was positive only for benzodiazepines, the urinalysis was normal, and her urine pregnancy was negative.\nThyroid function tests were sent, which revealed abnormal results with a thyroid stimulating hormone level of 0.01 U/mL (normal 0.3–5 U/mL), free T4 of 4.08 ng/dL (normal 0.8–2.8 ng/dL), and T3 of 9 ng/mL (normal 75–200 ng/dL). Combining these results, which demonstrated a hyperthyroid state, with the patient’s constellation of signs and symptoms culminated in the diagnosis of a severe thyroid storm.