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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?
Low serum iron
Elevated thyroid stimulating hormone (TSH)
Low vitamin D
Elevated human chorionic gonadotropin (hCG)
No specific lab abnormalities
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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 90/65 mmHg, pulse is 70/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?
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?
Anti-DNA topoisomerase antibodies
Anti-histidyl-tRNA synthetase antibodies
Anti-thyroid peroxidase antibodies
5-hydroxyindoleacetic acid in CSF