Hypothyroidism is considered by many as a "great mimicker" of many common complaints in the emergency department (ED). Thyroid disorders pose a significant threat when prolonged or in the acute presentation, and are potentially serious disorders with symptoms that range from non-specific constitutional to subtle or frank neuropsychiatric symptoms. Untreated disease can lead to myxedema crisis or coma, a life-threatening presentation that is rarely identified in young male patients and carries by itself a high risk of mortality, even in cases that undergo proper medical management. We present a case of a 26-year-old non-smoker Hispanic man with a medical history of hypothyroidism since the age of 13, and bronchial asthma. In a period of 3 -4 months, he developed generalized malaise, fatigue, cold intolerance and unintentional weight loss. He visited the ED after developing acute abdominal pain associated with non-bloody watery diarrheas. At the initial evaluation, vital signs revealed hypotension, borderline low heart rate, and hypoglycemia. On physical examination, he looked pale, appeared lethargic, with facial puffiness, macroglossia and bilateral hyporeflexia with delayed relaxation on muscle stretch reflexes. The laboratory results showed a thyroid stimulating hormone (TSH) of 314.75 uIU/mL. There was also low sodium and elevated creatinine and hepatic enzymes levels. Abdominopelvic CT scan incidentally revealed a large pericardial effusion that was later confirmed with echocardiogram. A diagnosis of myxedema crisis was established, prompt initiation of intravenous hydrocortisone, levothyroxine and triiodothyronine therapy was administered, and he was transferred to another institution for management of the pericardial effusion. This case raised concerns about the incidence where thyroid disease presentations are not identified and where patients fail to receive adequate medical therapy. We as primary care physicians should encourage patients to adhere to medical therapy and the recommended follow-up instructions to avoid catastrophic complications such as myxedema crisis.

Colorectal cancer is the third most lethal cancer in the United States and is the third most common type of cancer. In 2016, 134,490 cases of colorectal cancer were diagnosed in the United States. The diagnosis is usually made with screening colonoscopy on asymptomatic patients, while other patients are diagnosed after presenting symptoms such as hematochezia, iron deficiency anemia, changes in bowel movements, and abdominal pain. Also on emergency surgical procedures, a tumor may be found. We present a case of a 50-year-old Hispanic woman, G3P3AO, with a past medical history of hypertension, major depressive disorder and hysterectomy in 2003 without any toxic habits or family history of colon cancer or inflammatory bowel disease. Patient arrived with left lower quadrant pain, fever, and loss of appetite and was treated with IV antibiotics for an acute diverticulitis. Patient had multiple visits to urgency room for fecal material that discharged from the vaginal area and multiple intraabdominal abscesses in addition to obstruction. On imaging studies, patient had rectovaginal fistula and multiple abscesses. The patient's clinical condition became more complicated with enterocutaneous fistula and enterocolonic fistula 4 months later, suggesting inflammatory bowel disease. Sigmoid adenocarcinoma was diagnosed on the second colonoscopy. The clinical presentations of this patient with multiple abscesses and fistulas are commonly found on inflammatory bowel disease and can also be found in complicated intraabdominal infections. Rectovaginal fistulas which were the first fistula more commonly are caused by obstetric complications. Other common causes associated include surgery, inflammatory bowel disease, radiation therapy, and malignancy. These findings can mask the diagnosis of colorectal cancer and make the diagnosis challenging.