A 26 yo F comes to the office sue to persistent fatigue and inability to loose weight. She has also experienced hair loss and dry skin. The pt was diagnosed with primary hypothyroidism 2 years ago and was started on levothyroxine therapy, which she takes on an empty stomach every morning. She exercises 5 times per week, follows very stric caloric restrictions, and has eliminated gluten containing foods from her diet. Medical hx is unremarkable, and the pt has never been pregnant. In addition to levothyroxine, she also takes cyclic estrogen-progestin PO contraceptive. The pt is sexually active with one partner and does not use tobacco, alcohol, or illicit drugs.
BO is 125/80, PR 70, BMI 26. The thyroid gland is diffusely enlarged, firm, and nontender, and the remainder of the PE is normal.
- TSH 2.2
- Free T4 1.6
Which of the following is the most appropriate next step in management?
A. Add T3 to current therapy
B. Continue current tx and evaluate other etiologies
C. d/c PO contraceptives
D. increase levothyroxine does
E. initiate selenium therapy
A 78 yp F is brought to the office by her daughter due to intermittedn dizziness, weakness, and confusion. The pt was seen for fever and dysuria 3 days ago and started on trimethoprom/sulfamethoxazole. Her other medical problems include T2DM, HTN, and CKD with a baseline serum creat of 1.3. Her chronic medications include HCTZ, amlodipine, glyburide, atorvastatin, calcium, vitamin D, and alendronate.
Her temp is 36.8, BP is 140/85 supine and 144.89 standing, PR is 84, and RR is 20. BMI is 19. There are no focal neurologic findings. Her mini-mental state exam score is 24/20
- leukocytes 7,300
- Sodium 136
- K 3.6
- Bicarb 24
- Creat 1.4
- Glucose 70
- protein trace
- leukocyte esterate trace
- Nitrites negative
- bacteria few
- WBC 10-15
- RBC 3-5
- casts none
- HbA1c 6.1
Which of the following is the best next step in management?
A. d/c glyburide
B. d/c HCTZ
C. order CT of the head
D. Order renal US
E. Send urine Cx and adjusts abx.
A 6 day old boy is brought to the ER with a 2 hx of decreased PO intake and fussiness and a 1 day hx of vomiting. According to his parents, "he wouldn't wake up to feed this afternoon." He is exclusively breastfed and has been making normal number of wet diapers. The infant was born vaginally to a23 yo primigravidi mother following an uncomplicated pregnancy. ROS is negative for fever or sick contacts. His birth weight was 3.5; current weight is 3kg. His temp is 36.7, BP 70/30, PR 205, and RR are 48. PE shows a lethargic infant with a sunken fontanelle, poor skin turgor, and cap refil time of >5 secs. The extremities are cool. No hepatosplenomegaly, petechiae, or purpura is seen. He has a normal uncircumcised phallus and bilaterally descended testicles. An IV line is placed and 20mL/kg of NS is administered. Lab as follows;
Which of the following tests would most likely indicate this pt's underlying condition?
A. 17 hydroxyprogesterone level
B. Head CT
C. Lumber puncture
D. Renal US
A 55 year old male comes to the office due to fatigue and inability to maintain satisfactory erections during intercourse. He has also noticed decreased early morning erections and sexual desire. The patient has had no headache, visual symptoms, polyuria, head injuries, or motor weakness. He has been trying to lose weight with diet and exercise. Medical history is notable for pre-diabetes, hypertension, and hypertryglyceridemia, and current medication including lisinopril, atorvastatin, and ask Eileen. The patient's father had type two diabetes and died of sudden cardiac arrest at age 74. His sister has hypothyroidism. He lives with his wife and 20 year old son.
BP 142/74, PR 78, BMI 38. Body and facial hair distribution is normal. Visual fields are normal on confrontation.Testes no more in size but have soft consistency. The reminder of the physical exam is normal.
Which of the following is the best next step and evaluation of this patient's symptoms?
A. free testosterone level
B. LH and FSH level
C. MRI of the pituitary
D. Nocturnal penile tumescenece
E. Total testosterone level.
An 82 years old female comes to the office due to fatigue. For the last six months since her husband died, she has had low energy associated with decreased appetite. The patient has had no weight change, fevers, chills, night sweats. She sleeps 5 to 6 hours a night. Medical history is notable for hypertension, depression, and osteoporosis, for which she takes HCTZ, sertrakine, and alendronate, respectively. She does not smoke, and she drinks alcohol only once or twice a year on social occasions.
BT 36.8, BP 128/82, PR 68, BMI 24. A&Ox3. Neck examination is WNL. Abkle reflexes are absent.
Free T4 1.1
Which of the following is the most appropriate next step in management of this pt's Sx?
A. initiate low dose levothyroxine treatment
B. obtain periodic thyroid function studies
C. Order serum free T3 level
D. Order thyroid US
E. Order thyrotropin receptor antibody titer.