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A 48-year-old woman was brought to the hospital by her family because of diffuse, nonspecific pain. She was unable to provide her medical history. During the first hospital day, hypothermia (temperature, 34.8°C), bradycardia, and hypotension developed and the patient became obtunded. Physical examination was notable for dry skin, thin hair, a surgical scar on the neck, and delayed relaxation phase of the biceps reflex (see the video clip, available with the full text of this article at www.nejm.org). Laboratory evaluation was unremarkable except for an ionized calcium level of 0.96 mmol per liter, a thyrotropin level of 35 IU per milliliter, and a free thyroxine level of 0.4 ng per deciliter. The patient was treated with intravenous thyroxine and made an excellent recovery. Once awake, the patient reported that she had undergone thyroidectomy for papillary thyroid cancer seven years earlier, as reflected by a thyroglobulin level of less than 0.3 ng per milliliter, indicating total thyroid resection. She also reported that she had been intermittently compliant with her thyroid-replacement medications and had stopped taking them several weeks before admission.
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