A 56-year-oldhttp://www.usmleforum.com/foru female - ritonavir

[ArchivalUser]

A 56-year-old female presents with lethargy, weight loss, nausea, vomiting, and constipation for the past two months. She is three years postmenopausal, and has no long-standing medical problems. She currently takes no prescription medications. She denies allergies to drugs. She does not use tobacco or alcohol. Her family history is positive for osteoporosis and hypertension. Her heart rate is 64/min and blood pressure is 124/66 mmHg. Her height is 5'3" (160cm) and she weighs 138 lbs (63kgs). She has mild pallor. The thyroid gland is normal. The chest is clear on auscultation. Heart sounds are normal. Neurological examination reveals hung-up ankle jerks. Abdominal examination is unremarkable. Laboratory tests reveal a hemoglobin of 11.2 g/dL, and a hematocrit of 34%. RBCs are normochromic and normocytic. Serum sodium is 129 mEq/dL , while the rest of the basic chemistries are normal. TSH is 0.35 μU/ml (normal 0.35-5.0 μU/ml) and free T4 is 0.5 μg/dl (normal 0.8 to 1.8 μg/dl). What is the next best step in this patient's care?



A.


Measurement of antithyroid antibodies



B.


TRH stimulation test



C.


Serum T3 levels



D.


Measurement of cortisol with cosyntropin stimulation



E.


Thyroglobulin levels

[ArchivalUser]

seems like a case of secondary or tertiary hypothyroid....i would go with (b).

[ArchivalUser]

perhaps A?

[ArchivalUser]

To assess primary hypoT(which is more common) we should check antithyroid Ab (answer A). If this is excluded and we think secondary hypoT due to insufficient TRH/TSH we should perform a TRH stimulation test (answer B).
I can't explain the vomiting.

[ArchivalUser]

I will go for DD.

She has hypoT and a sodium of 129, which means she may have Addison's . So D is the right ans.

[ArchivalUser]

Yes, I know I was wrong. The answer is D. But in the context of primary adrenal insufficiency (autoimmune) she seems to have autoimmune thyroiditis too.

[ArchivalUser]

The correct answer is DDD
As it is central Hopothyroidism, we should always check the adrenal status here...
If we treat hypothyroidism with out seeing adrenal insufficiency we will precipitate adrenal crisis..