Hyperthyroidism: 1.3% of the US population has hyperthyroid. Thyrotoxicosis = too much thyroid hormone activity. Remember, T4 is a prohormone and T3 is the bioactive form. Causes of hyperthyroidism are broad and include: inappropriate thyroid stimulation, autonomous release of excess thyroid hormone, excessive release of thyroid stores, extra-thyroid sources of hormone. Hyperthyroidism increases risk of all-cause cardiovascular mortality and incidence of Afib. Diagnosis of hyperthyroid made by TSH <0.1 and high free T4. Iodine uptake test helps to find nodules and differentiate from thyroiditis.

Thyroid Storm: an exacerbation of thyrotoxicosis leading to multi-organ failure. Mortality is high at 10-30%. Precipitating factors include: thyroid surgery, radioiodine treatment, medication and medication adjustment. Symptoms: febrile, tachycardic, agitation, seizures, psychosis, delirium, transaminitis. Diagnostic scoring system based upon signs and symptoms, not lab values. Treatment: propylthiouricil is available but not commonly recommended due to hepatic toxicity. Methimazole is preferred, but takes several hours to work. In the mean-time, use propanolol to decrease the effects of the hormone (the only beta blocker that crosses the BBB so is ideal at treating CNS symptoms). 1 hour after giving methimazole, can give iodine.

Acute Chest Syndrome: Any new pulmonary illness in sickle cell disease should be considered acute chest, although current diagnostic criteria require fever and/or respiratory symptoms plus infiltrate on CXR. Acute chest is the 2nd leading cause of hospitalization in SCD. It is most commonly brought about by infection (atypical pathogens, RSV, influenza) but can also be caused by fat embolism due to bone marrow infarction, micro-pulmonary infarcts, and hypoventilation from pain. Children are more likely than adults to present with fever. CXR findings may not be apparent until day 2 or 3 of illness. Treatment: IV or oral hydration, adequate analgesia to prevent splinting, incentive spirometry, bronchodilators, emperic antibiotics for pneumonia, blood transfusion. Our hematology group prefers exchange transfusion, especially if patient deteriorate despite other therapies, require intubation, or have history of prior intubation. There is no role for steroids.

Inferior MI: constitute 40-50% of all acute MIs. Can frequently be associated with RV or posterior ischemia. Complicated by bradycardia and hypotension. More likely to present with GI symptoms and not classing crushing CP. EKG findings: ST depression in aVL or TWI in aVL. Remember, repeat EKGs save lives!

Serotonin Syndrome: 14-16% of cases are due to intentional overdose. Symptom onset is usually rapid (12-24 hours). Symptoms include 1) AMS: confusion, hypomania, agitation, disorientation, coma, seizures 2) neuromuscular abnormalities: clonus, rigitidiy, hyper-reflexia, increased tone, ataxia 3) autonomic instability: fever, mydriasis, diaphoresis. Labs are non-specific so must rely on history and physical for the diagnosis. Treatment: supportive therapy and withdrawal of offending agent: IV fluids, benzos for aggitation, cyproheptadine is a seratonin angatonist that can be used in severe cases. If you need to intubate, don't use succinylcholine.