Case Presentation: A 62-year-old woman with a history of chronic kidney disease (stage 5) and acquired hypothyroidism secondary to radioactive iodine therapy for multinodular goiter presented with subacute slowed mentation, difficulty concentrating, slurred speech, visual hallucinations, and fatigue. Review of systems revealed cold intolerance, constipation, and dry skin. She was adherent to her daily levothyroxine. [...]