Hypothyroidism

Symptoms: fatigue, wt gain, cold intolerance, constipation, myalgia, menstrual irregularities, depression, coarse features

Causes: Hashimoto’s thyroiditis, sick euthyroid syndrome, thyroidectomy, iodine deficiency or excess, drugs- lithium, amiodarone, infiltrative diseases- fibrous thyroiditis, hemachromatosis, sarcoidosis, congenital thyroid agenesis

Transient causes: painless (lymphocytic) thyroiditis, subacute granulomatous thyroiditis, post partum thyroiditis, subtotal thyroidectomy, following radioiodine for Graves’ dz,

Central hypothyroidism: TSH deficiency, TRH deficiency

3 HYPOTHALAMUS TRH

2 PITUITARY TSH

1 THYROID T4

0 BODY T3

First test TSH, if crazy high, repeat and get free T4

First Test TSH	Second Test Free T4	Clinical Status	Third Test
High	Low	1 Hypothyroidism	none
High	Normal	Subclinical hypothyroidism	TRH (if inc TSH, know it is not pituitary)
High	High	Pituitary hyperthyroidism	none

Screening: women ages 35-50 every 5 yrs

Treatment: T4 (synthroid, levothyroxine), check 3-6 wks for improvement in TSH
Treat subclinical hypothyroidism if sx, goiter, and TSH between 5-15, Treat elderly with low doses, Treat poorly compliant patients with weekly doses

Risk for over treatment: atrial fibrillation

Tips: if CK high, among other things, check TSH, if hyponatremic, check TSH, if hyperlipidemic, check TSH, if surgical patient has hypothyroidism, don’t have to hold surgery, but should treat

Myxedema Coma: treat aggressively, give T4 and T3. Give T3 until clinical improvement.

Sources: UpToDate, MedStudy Endocrinology section

Sepsis

Definitions

Systemic Inflammatory Response Syndrome (SIRS)

Two or more of the following:

Temp >38 or 100.4 or < 36 or 96.8

Heart rate >90/min

Respiratory rate >20/min or arterial blood PCO2 <32

Leukocyte count >12,000 or <4,000>

Sepsis= SIRS + known infection

Sever sepsis= sepsis associated with organ dysfunction, hypoperfusion, or hypotension

(lactic acidosis, oliguria, acute alteration in mental status)

Septic shock= sepsis-induced hypotension and perfusion abnormalities despite adequate fluid resuscitation

Pathophysiology

Abnormalities of coagulation and fibrinolysis which leads to a procoagulant state

Treatment

Treat the underlying cause, mostly with abx

Activated protein C (Xigris)- MHMC gives with strict precaution due to expense and bleeding tendency, need APACHE (Acute Physiology and Chronic Health Evaluation) score to be >24

Source- Infectious Disease Medicine in MKSAP