11-05-2010, 05:37 PM
A 32-year-old male presents to the office complaining
of severe anxiety. For the last 4 months, he has had difficulty
sleeping, progressively worsening nervousness,
a 25-pound weight loss, and constant feeling of “too
warm.” He feels “shaky” and has difficulty concentrating.
He denies diarrhea, but reports having
normally-shaped stools 4–5 times per day, more than
usual for him. The patient denies neck or eye discomfort,
and has not noticed any neck swelling. He admits
to smoking a half pack of cigarettes per day, a habit that
he started recently to “help him calm down.” He
denies alcohol or illicit drug use. His only medication
is an antihistamine for seasonal allergies. He has no
other significant medical history. His mother, who died
3 years ago from coronary artery disease, had a “thyroid
problem,” but he doesn’t know any more details.
Physical exam reveals an anxious young adult male.
He has a noticeable resting tremor. You note mild
exophthalmos, conjunctival injection, and lid lag. His
thyroid is diffusely, mildly enlarged and a bruit is audible
over the gland. The cardiac exam reveals tachycardia
with a flow murmur. The rest of the exam is
unremarkable.
What is the most likely diagnosis?
A) Viral thyroiditis.
B) Graves disease.
C) Anaplastic thyroid carcinoma.
D) Hyperactive thyroid adenoma.
E) Surreptitious thyroid hormone ingestion
Which of the following tests is most SPECIFIC
for Graves disease?
A) Antithyrotropin receptor antibody.
B) Antithyroglobulin antibody.
C) Antithyroid peroxidase antibody.
D) Markedly suppressed TSH.
E) No futhur testing
How should the patient be treated acutely?
A) Propanolol and propylthiouracil (PTU) started
immediately.
B) Control the patient’s symptoms with propanolol
now, then start PTU when the patient feels better.
C) Iodine (Lugol solution).
D) Radioablation with I131 .
E) Thyroidectomy.
Which of the following is a possible side effect of
PTU therapy?
A) Granulocytopenia.
B) Aplastic anemia.
C) Elevated liver transaminases.
D) Inhibition of fetal thyroid gland.
E) All of the above