11-07-2010, 04:25 PM
What is the answer for this Qs
q146 - sami2004
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11-07-2010, 04:25 PM
What is the answer for this Qs
11-07-2010, 05:48 PM
BDAE.
11-08-2010, 05:14 AM
The correct answer is B. This is a classic presentation
of Graves disease. The family history, the symptoms and signs of hyperthyroidism (especially the diffusely enlarged goiter with a bruit), and the exophthalmos are all typical. Conjunctival infection is also frequently noted. Answer A is unlikely. Viral thyroiditis can cause hyperthyroidism and a goiter, but the thyroid gland is usually tender. Also, viral thyroiditis will likely not last 4 months, but is usually self-limited to a few weeks. Anaplastic carcinoma is a devastating disease with a dismal prognosis: the thyroid gets very large very quickly, but the disease does not present with hyperthyroidism. A hyperactive adenoma and surreptitious ingestion of thyroid hormone would not cause a goiter or exophthalmos The correct answer is A. Graves disease is an autoimmune process, and lymphocytes in the thyroid gland itself are responsible for a large amount of the thyroid autoantibodies produced. Although several types of antibodies can be tested, antithyrotropin receptor antibody is the most specific. Antithyrotropin receptor antibody is found in 80% to 95% of patients with Graves disease and in essentially no other condition (although it may be elevated in 10% to 20% of those with other forms of autoimmune thyroiditis). Antithyroglobulin antibodies (answer B) are found in Graves disease, autoimmune thyroiditis, some patients with type 1 diabetes, and in up to 20% of the general population. Antithyroid peroxidase antibody (answer C) is elevated in Graves disease, autoimmune thyroiditis, type 1 diabetes, some pregnant patients, etc. The correct answer is A. There is no need to wait before starting propylthiouracil (PTU) or the alternative methimazole (Tapazole), which block production of thyroid hormone. PTU is a better choice in those with significant symptoms because it will also partially block the peripheral conversion of T4 (inactive) to T3 (active form). Propanolol is helpful for controlling the symptoms of hyperthyroidism (tachycardia, tremor, etc). Iodine will provide further substrate for the body in the production of thyroid hormone and should not be given unless a thyroid-blocking agent has been started. Iodine is useful during thyroid storm to prevent the release of stored thyroid hormone, but it is given one hour after PTU or methimazole. Radioablation is used for patients who prove refractory to medicine or have poor compliance. Thyroidectomy is rarely used for Graves in current medical practice because of the ease and efficacy of radioactive iodine administration (except in the case of pregnancy and a few other unusual cases). The correct answer is E. All of the above are known side effects of antithyroid drugs (thioamides). Granulocytopenia occurs in about 0.5% of patients and is a sudden, idiosyncratic reaction. Classically, patients present with a severe sore throat. If you have a patient on PTU with a sore throat, check a CBC. Aplastic anemia may occur but is rare. For these reasons, patients starting these medications should have a baseline CBC. Mild, transient elevation of the liver transaminases is common, and the drug should be discontinued if the level is greater than three times normal. Both PTU and methimazole cross the placenta and will inhibit the fetal thyroid, increasing the risk for congential hypothyroidism. The risk to a fetus posed by the drugs is less than the danger posed by a mother with accelerating hyperthyroidism, so the medications should be used even during pregnancy if indicated. PTU is regarded as slightly safer in pregnancy. Nonetheless, you should use the smallest dose possible. If a pregnant patient is not controlled with PTU, consider surgical thyroidectomy.
11-08-2010, 09:37 AM
Can I know the source of this Q, Sami? In US I131 radioablation is the ist line treatment for graves in young pt's who have no CIs to its use.
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