Snapshot A 38-year-old woman presents to her primary care physician with complaints of increased fatigue. On further review, she also reports that she has been experiencing a 15-pound weight gain, cold intolerance, and constipation over the past few months. On physical exam, she is bradycardic, has a puffy face with periorbital edema, has thinning hair, exhibits delayed relaxation of deep tendon reflexes, and is without a goiter. Introduction Clinical definition primary hypothyroidism due to the autoimmune destruction of the thyroid gland Epidemiology most common cause of primary hypothyroidism predominantly female (10-15 x higher) 30-50 years of age Risk factors family history autoimmune disease Pathogenesis anti-thyroid antibodies destroy thyroid cells leading to insufficient production of thyroid hormone anti-thyroid peroxidase anti-thyroglobulin damaged thyroid cells can initially leak stored thyroid hormone into circulation leading to transient hyperthyroidism before the onset of hypothyroidism Associated conditions pernicious anemia celiac disease type 1 diabetes Prognosis excellent with treatment myxedema coma has a high mortality rate Presentation Symptoms weakness and fatigue cold intolerance constipation and ileus weight gain depression, slow mentation, and inability to concentrate heavy menstruation galactorrhea thyrotropin-releasing hormone can stimulate prolactin secretion hoarseness myopathy dementia/memory loss Physical exam dry and cold skin puffy face with periorbital edema non-pitting edema (myxedema due to glycosaminoglycan in the interstitium) thinning hair and nails bradycardia delayed relaxation of the deep tendon reflexes thyroid gland can be atrophic, normal, or enlarged Special presentation subclinical elevated thyroid stimulating hormone (TSH) but normal thyroid hormones does not require treatment unless auto-antibody positive or symptomatic Studies Diagnostic testing diagnostic approach screen and confirm with lab tests studies TSH and free T4 primary screening TSH is the most sensitive measure lab results may be confounded by high doses of biotin supplementation autoantibody diagnose Hashimoto versus other etiologies of hypothyroidism anti-thyroid peroxidase (90% of cases) anti-thyroglobulin (50% of cases) 10-15% are antibody negative imaging not routinely indicated biopsy fine needle aspiration for any dominant nodule or fast-growing goiter histopathology is the gold standard for diagnosis but invasive diffuse lymphocytic and plasma cell infiltration is characteristic of Hashimoto thyroiditis Diagnostic criteria ↑ TSH and ↓ free T4 in early disease, TSH and free T4 may be normal positive antithyroid autoantibodies Differential Euthyroid sick syndrome distinguishing factors ↓ thyroid hormone but also ↓TSH secondary to nonthyroidal systemic illness Thyroid lymphoma distinguishing factors rapidly enlarging goiter lymphoma on histopathology Panhypopituitarism distinguishing factor loss of pituitary hormones in addition to ↓ T4 including ↓ cortisol, ↓ sex steroids, ↓ growth hormone, and ↓ antidiuretic hormone Major depressive disorder distinguishing factor lack of cold intolerance, integumentary changes, myxedema, and goiter Treatment Management approach thyroid hormone replacement to achieve a euthyroid state within 2-4 weeks monitor clinically and with TSH monitor for other associated complications mild anemia ↑ total cholesterol, low-density lipoprotein, and triglycerides ↓ high-density lipoprotein hyponatremia First-line lifelong levothyroxine replacement requires adjustment during pregnancy adverse effects include overreplacement leading to osteoporosis and arrhythmias administer empirically without lab confirmation in myxedema coma Second line surgery indicated for obstructive symptoms (dysphagia, stridor, and hoarseness), malignancy, and cosmesis Complications Thyroid lymphoma or other thyroid malignancy Iatrogenic overreplacement Myxedema coma life threatening complication of hypothyroidism start empiric treatment with IV levothyroxine if high suspicion can support diagnosis with TSH and free T4 level
QUESTIONS 1 of 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.EC.17.4868) A 57-year-old woman presents to her primary care physician for weakness. The patient states that she barely feels able to lift a bag of groceries from her car into her house anymore. The patient has a past medical history of a suicide attempt, constipation, anxiety, asthma, and atopic dermatitis. Her current medications include fluoxetine, lisinopril, albuterol, diphenhydramine, sodium docusate, and a multivitamin. She was recently started on atorvastatin for dyslipidemia. Her temperature is 97°F (36.1°C), blood pressure is 150/95 mmHg, pulse is 50/min, respirations are 11/min, and oxygen saturation is 98% on room air. On physical exam, you note a fatigued appearing woman with thinning hair. Cardiopulmonary exam is within normal limits. She demonstrates 3/5 strength in her upper and lower extremities with 1+ sluggish reflexes. Sensation is symmetrical and present in the upper and lower extremities. Pain/tenderness upon palpation of the patient's extremities is noted. Laboratory values are ordered as seen below:Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 5,500/mm^3 with normal differential Platelet count: 190,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 101 mEq/L K+: 4.4 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 90 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.1 mg/dL AST: 12 U/L ALT: 10 U/LWhich of the following is the best next step in management? QID: 109578 Type & Select Correct Answer 1 Discontinue atorvastatin 23% (16/70) 2 Coenzyme Q10 1% (1/70) 3 TSH level 69% (48/70) 4 Aldolase level 3% (2/70) 5 Muscle biopsy 3% (2/70) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M2.EC.17.4753) A 26-year-old Caucasian female presents to her primary care physician in January with several months of worsening fatigue and weight gain. She reports a gradual onset of daytime fatigue as well as difficulty sleeping, and she has been drinking several cups of coffee a day to stay awake at work. She notes that her new job involves long hours such that she often does not see daylight. She also feels that despite her appetite being unchanged, she has gained 12 pounds, mostly in her abdomen and hips. On review of systems, she also reports new onset constipation and noticed one episode of painless bright red blood per rectum on wiping. In addition, she has missed her menses in the last three months, which is unusual for her. She is sexually active and uses inconsistent contraception. She has a family history of type I diabetes in her sister and vitiligo in her mother. At this visit, the patient’s temperature is 98.5°F (36.9°C), blood pressure is 124/77 mmHg, pulse is 70/min, and respirations are 14/min. On exam, the patient appears tired but comfortable and conversant. The patient's eyebrows appear as those in Figure A, and the skin on her hands and face is noted to be dry. She has a capillary refill of 2 seconds, and there is no palpable thyroid nodularity or enlargement. The remainder of her exam is unremarkable. Which of the following laboratory abnormalities is most likely present in this patient? QID: 108822 FIGURES: A Type & Select Correct Answer 1 Low serum iron 0% (0/32) 2 Elevated thyroid stimulating hormone (TSH) 75% (24/32) 3 Low vitamin D 9% (3/32) 4 Elevated human chorionic gonadotropin (hCG) 9% (3/32) 5 No specific lab abnormalities 3% (1/32) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (M2.EC.17.4755) A 57-year-old female presents to her primary care physician with a chief complaint of feeling tired all the time. She states her symptoms began several months ago, around the time that her husband committed suicide. Since then she has had thoughts of joining her husband. She complains of feeling excessively weak and states that she no longer has enough energy to go to the gym which she attributes to her 15 pound weight gain over the last month. The patient's medical history includes joint pain, a skin rash that recently resolved, obstructive sleep apnea, and metabolic syndrome. The patient takes ibuprofen and omeprazole as needed but otherwise cannot remember any other medications that she takes. On physical exam you note an overweight woman who has an overall depressed affect. The patient's cardiac exam reveals a normal rate and rhythm. The pulmonary exam reveals bilateral clear lung fields with good air movement. The patient's skin is very dry and tight appearing and her hair is coarse. Overall the patient appears somewhat unkempt.Laboratory work is performed and reveals the following:Hemoglobin: 13.0 g/dLHematocrit: 37%Leukocyte count: 4,500 cells/mm^3 with normal differentialPlatelets: 250,000/mm^3Serum:Na+: 140 mEq/LK+: 4.4 mEq/LCl-: 102 mEq/LBUN: 15 mg/dLGlucose: 122 mg/dLCreatinine: 1.0 mg/dLThyroid-stimulating hormone: 5.3 µU/mLCa2+: 10.2 mg/dLAST: 11 U/LALT: 13 U/LWhich of the following laboratory findings is most likely to be abnormal in this patient? QID: 108705 Type & Select Correct Answer 1 Anti-DNA topoisomerase antibodies 16% (5/32) 2 Anti-nuclear antibodies 3% (1/32) 3 Anti-histidyl-tRNA synthetase antibodies 0% (0/32) 4 Anti-thyroid peroxidase antibodies 78% (25/32) 5 5-hydroxyindoleacetic acid in CSF 3% (1/32) M 5 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.OMB.4875) A 67-year-old woman presents from a nursing home with altered mental status. She was last known to be normal the night before. The patient has dementia at baseline and is minimally interactive. This morning, she was found to be obtunded. No further history was provided from the nursing home, and the patient is unable to provide any history. Her temperature is 95.0°F (35.0°C), blood pressure is 84/54 mmHg, pulse is 50/min, respirations are 9/min, and oxygen saturation is 98% on room air. Physical exam reveals an obtunded woman who only withdraws her extremities to pain. Her skin is cool and pale, and her hair is thin. There are no signs of trauma noted on exam. Laboratory values are notable for a whole blood sodium of 120 mEq/L. The patient is given several intravenous boluses of fluids and her blood pressure improves to 100/60 mmHg. Which of the following is most likely to confirm the underlying cause of this patient's symptoms? QID: 216396 Type & Select Correct Answer 1 Administer glucagon 0% (0/0) 2 Check serum TSH and free T4 levels 0% (0/0) 3 Obtain blood cultures and a serum lactate 0% (0/0) 4 Perform a CT scan of the head 0% (0/0) 5 Perform an echocardiogram 0% (0/0) M 10 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (M2.OMB.4876) A 77-year-old man presents to the emergency department acutely obtunded. The patient lives alone and was found unresponsive by his son. Generally, the patient manages his own finances, medications, and works part-time. He has not been responding to phone calls for the past 3 days. The patient is unable to offer a history. He has a past medical history of hypothyroidism, depression, and diabetes. His temperature is 88.0°F (31.1°C), blood pressure is 92/62 mmHg, pulse is 35/min, respirations are 9/min, and oxygen saturation is 92% on room air. The patient is cold to the touch and moves all extremities to painful stimuli. His pupils are reactive and sluggish, and he does not follow commands. There are no signs of trauma or skin infections. The patient is started on IV fluids and hydrocortisone, is externally warmed, and is started on a norepinephrine drip. An ECG is performed as seen in Figure A. Which of the following is the most appropriate next step in management? QID: 216587 FIGURES: A Type & Select Correct Answer 1 Free T4 level 0% (0/0) 2 Levothyroxine administration 0% (0/0) 3 Thyroid stimulating hormone and free T4 level 0% (0/0) 4 Thyroid stimulating hormone level 0% (0/0) 5 Triiodothyronine administration 0% (0/0) M 11 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
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