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1 Early Frequent symptoms are fatigue, lethargy, weakness, arthralgias or myalgias, muscle cramps, cold intolerance, constipation, dry skin, headache, and menorrhagia Physical findings may be few or absent Features may include thin, brittle nails, thinning of hair, and pallor Delayed relaxation of deep tendon reflexes and bradycardia are sometimes noted 2 Late The symptoms are variable but may include slow speech, absence of sweating, constipation, peripheral edema, pallor, hoarseness, decreased sense of taste and smell, muscle cramps, aches and pains, dyspnea, weight changes (usually gain, but weight loss is not rare), and diminished auditory acuity Some women have amenorrhea; others have menorrhagia Galactorrhea may also be present Physical findings may include goiter; puffiness of the face and eyelids; typical carotenemic skin color; thinning of the outer halves of the eyebrows; thickening of the tongue; hard pitting edema; and effusions into the pleural, peritoneal, and pericardial cavities as well as into joints Cardiac enlargement ( myxedema heart ) is often due to pericardial effusion The heart rate is slow; the blood pressure is more often normal than low, and reversible diastolic hypertension may be found Hypothermia may be present Pituitary enlargement due to hyperplasia of TSH-secreting cells, which is reversible following thyroid therapy, may be seen in long-standing hypothyroidism Hypothyroidism rarely causes true obesity

Complications are mostly cardiac in nature, occurring as a result of advanced coronary artery disease and congestive heart failure, which may be precipitated by overly vigorous thyroid therapy There is an increased susceptibility to infection Megacolon has been described in long-standing hypothyroidism Organic psychoses with paranoid delusions may occur ( myxedema madness ) Rarely, adrenal crisis may be precipitated by thyroid therapy Hypothyroidism is a rare cause of infertility, which may respond to thyroid medication Pregnancy in a woman with untreated hypothyroidism often results in miscarriage On the other hand, if the hypothyroidism is due to autoimmune disease, it may improve during pregnancy Sellar enlargement and even well-defined TSHsecreting tumors may develop in untreated cases These tumors decrease in size after replacement therapy is instituted A rare complication of severe hypothyroidism is deep stupor, at times progressing to myxedema coma, with severe hypothermia, hypoventilation, hyponatremia, hypoglycemia, and hypotension Convulsions and abnormal central nervous system signs may occur Myxedema coma is often induced by an underlying infection; cardiac, respiratory, or central ner-

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vous system illness; cold exposure; or drug use It is most often seen in elderly women The mortality rate from myxedema coma is high Myxedematous patients are unusually sensitive to opioids and may die from average doses Refractory hyponatremia is often seen in severe myxedema Inappropriate secretion of ADH has been observed in some patients, but a defect in distal tubular reabsorption of sodium and water has been demonstrated in many others

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Question 4-6. Let myInt = 25 to start. What is the value of myInt at each stage of the following code

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