As the shift begins, you are assigned to care for the following patients. Which patient should you assess first?

As the shift begins, you are assigned to care for the following patients. Which patient should you assess first?

• A. 38-year-old with Graves disease and a heart rate of 94 beats/ min
• B. 63-year-old with type 2 diabetes and fingerstick glucose level of 137 mg/ dL
• C. 58-year-old with hypothyroidism and a heart rate of 48 beats/ min
• D. 49-year-old with Cushing disease and dependent edema rated as 1 +

Answer: (C)

The most important concept here is prioritizing care for the patient who may be rapidly deteriorating. A heart rate of 48 beats per minute in a patient with known hypothyroidism raises strong concern for myxedema coma, a life-threatening emergency. In this scenario, bradycardia can reflect severely reduced metabolic function and can be accompanied by hypoventilation, hypotension, and altered mental status. Because of the potential for rapid decompensation, this patient should be assessed first to determine airway, breathing, and circulation status and to implement urgent supportive measures as needed. In contrast, the patient with Graves disease has mild tachycardia that is common with hyperthyroidism but not an immediate threat by itself; the fingerstick glucose is normal, which doesn’t signal an acute crisis, and the Cushing disease patient has mild edema that is less acutely dangerous. So the bradycardic patient requires the quickest assessment to rule out or address possible myxedema and prevent progression to a more unstable state. Focus first on airway and breathing, check mental status, measure blood pressure, assess temperature, and prepare to escalate if signs of instability or hypoxia are present.

The most important concept here is prioritizing care for the patient who may be rapidly deteriorating. A heart rate of 48 beats per minute in a patient with known hypothyroidism raises strong concern for myxedema coma, a life-threatening emergency. In this scenario, bradycardia can reflect severely reduced metabolic function and can be accompanied by hypoventilation, hypotension, and altered mental status. Because of the potential for rapid decompensation, this patient should be assessed first to determine airway, breathing, and circulation status and to implement urgent supportive measures as needed.

In contrast, the patient with Graves disease has mild tachycardia that is common with hyperthyroidism but not an immediate threat by itself; the fingerstick glucose is normal, which doesn’t signal an acute crisis, and the Cushing disease patient has mild edema that is less acutely dangerous. So the bradycardic patient requires the quickest assessment to rule out or address possible myxedema and prevent progression to a more unstable state. Focus first on airway and breathing, check mental status, measure blood pressure, assess temperature, and prepare to escalate if signs of instability or hypoxia are present.