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A 35-year-old homeless woman presents to the emergency department complaining of a strange sensation in her chest. The patient is disheveled and dirty. The patient is an immigrant and does not speak English. On physical exam you note a sweaty and nervous woman who demonstrates a mild tremor and proptosis. Her pulse is 110/minute, temperature is 99°F (37.3°C), and blood pressure is 110/70 mmHg. IV fluids are started. An EKG is performed and the findings are shown in Figure A. Initial labs are drawn and pending. A urine toxicology returns negative for testable illicit substances. Which of the following is the next best step in management?
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A 26-year-old G1P0 presents to her first obstetric visit after having a positive urine pregnancy test at home. Her last menstrual period was 9 weeks ago. She has no past medical history, but her mother has rheumatoid arthritis. The patient states that for several weeks, she has felt especially warm, even when her co-workers do not, and had muscle weakness. She also complains of mood swings and fatigue. At this visit, her temperature is 99.0°F (37.2°C), blood pressure is 140/81 mmHg, pulse is 106/min, and respirations are 17/min. Physical exam is notable for 3+ deep tendon reflexes bilaterally and 4/5 strength in both hips and shoulders. Ultrasound confirms the presence of a heart beat and shows a crown rump length that is consistent with a gestational age of 9 weeks and 3 days. Which of the following is the best therapy for this patient?
Radioactive thyroid ablation (I-31)
A 40-year-old woman with a past medical history significant for pernicious anemia and vitiligo presents to the physician with the chief complaints of heat intolerance and frequent palpitations. The patient does not take birth control and her urine pregnancy test is negative today. Physical exam reveals a patient that is hyper-reflexive with a non-tender symmetrically enlarged thyroid gland. You order thyroid function tests for workup. What thyroid function values are most expected?
T4 elevated, free T4 normal, T3 elevated, thyroid stimulating hormone (TSH) normal
T4 elevated, free T4 elevated, T3 elevated, TSH elevated
T4 elevated, free T4 elevated, T3 elevated, TSH decreased
T4 decreased, free T4 decreased, T3 decreased, TSH decreased
T4 normal, free T4 normal, T3 normal, TSH elevated
A 32-year-old woman presents to the emergency department with a 1-month history of heat intolerance, a racing heart, unintentional 4-pound weight loss, and sweating. She states she is generally healthy and only takes a multivitamin. Her temperature is 100°F (37.8°C), blood pressure is 122/82 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 100% on room air. Physical exam is notable for a nontender and enlarged thyroid. HEENT exam is notable for the finding in Figure A which is mild. The patient's urine hCG is negative. Laboratory values are notable for a TSH of 0.1 mIU/L. What is the most appropriate definitive treatment for this patient?
No treatment is indicated
A 34-year-old woman presents to her primary care physician with insomnia. She notes that she has had difficulty calming down for the past several months. She also reports feeling warm, even when others feel cold, and that her eyes appear to bulge more than she remembered (Figure A). Her TSH is found to be 0.03 mcU/mL (nl 0.4-2.5 mcU/mL), and free T4 is 5 ng/dl (nl 0.7-1.9 ng/dl). She chooses to undergo radioiodine ablation, and returns to her physician 2 days after the procedure noting increased bulging of her eyes. Which of the following steps could have decreased the risk of this complication?
Pretreatment with a non-steroidal anti-inflammatory drug (NSAID)
Pretreatment with a beta blocker
Pretreatment with furosemide
Pretreatment with prednisone
Post-treatment with levothyroxine immediately after ablation
A 66-year-old man presents to the emergency department with palpitations. He has a history of hypertension and diabetes. His temperature is 97.6°F (36.4°C), blood pressure is 154/100 mmHg, pulse is 122/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, the patient is mentating normally and is in no acute distress. An ECG is performed as seen in Figure A. Initial laboratory studies including a CBC, serum chemistries, and 2 troponins are unremarkable. What is the most appropriate next step in management?