甲状腺、肾上腺和水调节激素

🧠 为什么重要

HYPERTHYROIDISM（甲状腺功能亢进，Graves' disease）：怕热、体重减轻、心动过速、震颤、眼球突出；用 methimazole 或 propylthiouracil、beta blockers 和放射性碘治疗。THYROID STORM（甲状腺风暴），由感染、手术或应激诱发：发热、严重心动过速、躁动和谵妄；用降温、beta blockers、抗甲状腺药物、碘和类固醇治疗。HYPOTHYROIDISM（甲状腺功能减退）：怕冷、体重增加、心动过缓、便秘、疲劳；每天早上空腹服用 levothyroxine，剂量由 TSH 检查决定。MYXEDEMA COMA（黏液性水肿昏迷）：低体温、低血压、心动过缓、通气不足和意识水平下降；先支持气道和呼吸，然后给予 IV levothyroxine 并同时给予 IV hydrocortisone，直到排除肾上腺功能不全，并用毯子等被动复温方式逐渐复温。THYROIDECTOMY（甲状腺切除术）后：床旁备气管切开包和 calcium gluconate，检查颈后是否有出血，听声音是否嘶哑，并注意手足搐搦。ADDISON'S DISEASE（Addison 病，肾上腺功能不全）：疲劳、体重减轻、皮肤呈青铜色、HYPOTENSION（低血压）、HYPONATREMIA（低钠血症）、HYPERKALEMIA（高钾血症）和低血糖；终身使用类固醇，绝不能突然停药，生病时要增加剂量。ADDISONIAN CRISIS（Addison 危象）：严重低血压和休克；给予 IV hydrocortisone、液体和 glucose。CUSHING'S SYNDROME（Cushing 综合征）：满月脸、水牛背、躯干性肥胖、紫纹、皮肤变薄、HYPERTENSION（高血压）、HYPERGLYCEMIA（高血糖）、HYPOKALEMIA（低钾血症）、骨质疏松和感染风险。DIABETES INSIPIDUS（尿崩症）：大量稀释尿（比重低于 1.005）、口渴和 HYPERNATREMIA（高钠血症）；中枢性 DI 用 desmopressin 治疗，而肾性 DI 用噻嗪类利尿剂、低钠饮食和去除病因（例如 lithium）治疗。SIADH：液体潴留、尿液浓缩和 HYPONATREMIA（低钠血症）；用限制液体治疗，严重时用高渗 saline。

HYPERTHYROIDISM (Graves' disease): heat intolerance, weight loss, tachycardia, tremor, exophthalmos; treated with methimazole or propylthiouracil, beta blockers and radioactive iodine. THYROID STORM, triggered by infection, surgery or stress: fever, severe tachycardia, agitation and delirium; treat with cooling, beta blockers, antithyroid drugs, iodine and steroids. HYPOTHYROIDISM: cold intolerance, weight gain, bradycardia, constipation, fatigue; levothyroxine every morning on an empty stomach, dose checked by TSH. MYXEDEMA COMA: hypothermia, hypotension, bradycardia, hypoventilation and decreased consciousness; support the airway and breathing first, then give IV levothyroxine with IV hydrocortisone until adrenal insufficiency is ruled out, and warm gradually with passive warming such as blankets. After THYROIDECTOMY: a tracheostomy set and calcium gluconate at the bedside, check behind the neck for bleeding, listen for a hoarse voice and watch for tetany. ADDISON'S DISEASE (adrenal insufficiency): fatigue, weight loss, bronze skin, HYPOTENSION, HYPONATREMIA, HYPERKALEMIA and hypoglycemia; lifelong steroids that are never stopped abruptly and are increased during illness. ADDISONIAN CRISIS: profound hypotension and shock; IV hydrocortisone, fluids and glucose. CUSHING'S SYNDROME: moon face, buffalo hump, truncal obesity, striae, thin skin, HYPERTENSION, HYPERGLYCEMIA, HYPOKALEMIA, osteoporosis and infection risk. DIABETES INSIPIDUS: massive dilute urine (specific gravity under 1.005), thirst and HYPERNATREMIA; central DI is treated with desmopressin, while nephrogenic DI is treated with thiazide diuretics, a low-sodium diet and removal of the cause (e.g., lithium). SIADH: fluid retention, concentrated urine and HYPONATREMIA; treat with fluid restriction and hypertonic saline when severe.

🏥 真实场景

🧂 一位因关节炎长期服用 prednisone 的患者因为“疼痛好多了”而停了药。三天后，她来到急诊科，血压为 76/40，钠为 126，glucose 为 58。被抑制多年的肾上腺无法作出反应。IV hydrocortisone 和液体逆转了危象。她需要的教导只有四个词：绝不能突然停用类固醇。

🧂 A client on long-term prednisone for arthritis stops taking it because 'the pain is better'. Three days later she is in the emergency department with a blood pressure of 76/40, a sodium of 126 and a glucose of 58. The adrenals, suppressed for years, cannot respond. IV hydrocortisone and fluids reverse the crisis. The teaching she needed was four words: never stop steroids abruptly.

📌 要点总结

• 甲状腺风暴：热而快；黏液性水肿昏迷：冷而慢Thyroid storm: hot and fast; myxedema coma: cold and slow
• Addison 病：低钠血症、高钾血症、低血压；绝不能突然停用类固醇Addison's: hyponatremia, hyperkalemia, hypotension; never stop steroids abruptly
• DI：稀释尿、高钠血症，中枢性 DI 用 desmopressin；SIADH：低钠血症，限制液体DI: dilute urine, hypernatremia, desmopressin for central DI; SIADH: hyponatremia, fluid restriction

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