A 25-Year-Old Man Comes to the Office with a 2-Month

question 330

Multiple Choice

A 25-year-old man comes to the office with a 2-month history of fatigue, palpitations, sweating, and heat intolerance.  The symptoms are becoming more distressing and are keeping the patient awake at night.  The patient has no diplopia, eye pain or redness, decreased vision, neck pain, or proximal muscle weakness.  Medical history is unremarkable, and he currently takes no medications.  He smoked for approximately a year during college but quit after graduation.  The patient drinks alcohol socially but does not use recreational drugs.  Family history is positive for hypothyroidism in his mother.  Temperature is 36.7 C (98 F) , blood pressure is 130/70 mm Hg, pulse is 115/min (regular) , and respirations are 18/min.  Examination shows an anxious, thin man in no acute distress.  There is mild lid lag but no conjunctival erythema or proptosis.  Extraocular movements and pupillary reflexes are intact.  Mild diffuse nontender enlargement of the thyroid gland is noted.  The skin is warm and moist.  Cardiac examination is unremarkable except for tachycardia.  Neurologic examination shows a fine hand tremor and brisk symmetrical reflexes but is otherwise unremarkable.  Laboratory tests show normal complete blood count, basic metabolic profile, and urinalysis.  Thyroid function test results are as follows: Radioactive iodine uptake at 24 hours is 36% (normal: 8%-25%) , and scan shows a diffuse uptake pattern.  Serum thyroid-stimulating immunoglobulin level is mildly elevated.
Which of the following is the best next step in management of this patient?

• A)Begin propylthiouracil only
• B)Perform radioactive iodine ablation only
• C)Prescribe oral glucocorticoid only
• D)Refer for thyroidectomy
• E)Start propranolol and methimazole

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Definitions:

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(1) In classical conditioning, the learned ability to distinguish between a conditioned stimulus and similar stimuli that do not signal an unconditioned stimulus; in operant conditioning, the ability to distinguish responses that are reinforced from similar responses that are not reinforced. (2) In social psychology, unjustifiable negative behavior toward a group or its members.

Intelligence Tests

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The capacity of an individual to achieve and perform academically, often taking into account intellectual capability, creativity, and motivation.