Regarding thyroid dysfunction in critically ill patients:
a) List the likely clinical and laboratory findings that are seen in a patient with severe hypothyroidism, that requires ICU management. (25% marks)
b) Outline your approach to managing this patient in a).
c) List the laboratory findings in ‘euthyroid sick’ syndrome (ESS) in a critically ill patient.
d) Outline your approach to managing a patient with ESS in the ICU.
It's difficult not to introduce false subtext into the exam stems, as this is a high-stakes piece of text, and people will surely scrutinise each letter as carefully as Biblical scholars, inflating the meaning of seemingly random choices of wording and grammar. For example, "list the likely clinical and laboratory findings" leaves the reader to wonder how many findings such a list ought to contain. These should be findings "that are seen in a patient with severe hypothyroidism, that requires ICU management", presumably implying that one should not list findings seen in relatively healthy community-based outpatients with hypothyroidism (and the comma in the middle is suspicious). And then, we are invited to "outline your approach to managing this patient in a)", but..... there is no specific patient case mentioned in a), only "a patient with severe hypothyroidism, that requires ICU management". What mysterious grade items lurk in the difference between this wording, and simply asking the candidates to "otline your approach to managing a patient with severe hypothyroidism in the ICU"?
Pushing down the paralysing fear that one completely misinterpreted the question, the following potential answer can be offered:
a) Clinical and laboratory findings in severe hypothyroidism: left without instructions regarding how many of these were required, the author has listed all of them; though one might make the argument that postural dizziness amenorrhoea and decreased libido are unlikely to be important in a patient that requires ICU management, and could have been omitted.
b) An approach to the management of the severely hypothyroid patient: for 40% of the total mark, this should have been a relatively thick paragraph or point-form list. What follows is a management plan for a patient with a very severe ICU-level hypothyroidism, bordering on myxoedema coma:
c) Features of sick euthyroid:
The sick euthyroid syndrome is a biochemical pattern of decreased circulating T3 levels, without a strong compensatory TSH response. The raised levels of rT3 result in a disproportionate degree of thyroid dysfunction, as rT3 is an inactive form, and therefore a competitive antagonist of "real" T3.
d) Management of sick euthyroid syndrome, in 90 seconds,
Farwell, Alan P. "Nonthyroidal illness syndrome." Current Opinion in Endocrinology, Diabetes and Obesity 20.5 (2013): 478-484.
De Groot, Leslie J. "Dangerous dogmas in medicine: the nonthyroidal illness syndrome." The Journal of Clinical Endocrinology & Metabolism 84.1 (1999): 151-164.
Ringel, Matthew D. "Management of hypothyroidism and hyperthyroidism in the intensive care unit." Critical care clinics 17.1 (2001): 59-74.
Almandoz, Jaime P., and Hossein Gharib. "Hypothyroidism: etiology, diagnosis, and management." Medical Clinics of North America 96.2 (2012): 203-221.