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Old 08-22-2014
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Help NBME 7 Qs - Please help !

42 year old woman comes to the physician because of a 4 month history of fatigue, palpitations and anxiety. She has had 3 kg ( 7 lb) weight loss during this period. She has also noted heat intolerance and increasing frequency of bowel movements. She has a 10 year history of asthma well controlled with inhaled albuterol .Her temperature is 37 C ( 98.6 F ) , pulse is 110/min and regular and blood pressure is 150/70 mm Hg. Examination shows lid lag and exophthalmos. The thyroid gland is large and non-tender, a thyroid bruit is heard. Deep tendon reflexes are normal. Serum studies show and thyroid stimulating hormone concentration of less than 0.1 U/ml and thyroxine (T4) concentration of 16U/ml. A thyroid scan shows a diffuse increased uptake. Which of the following is the most appropriate initial step in management.
A) Intravenous cortisol therapy
B) Intravenous sodium iodide therapy
C) Oral 131 therapy
D) Oral propylthiouracil therapy
E) Oral terazosin
F) Subtotal thyroidectomy
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Old 08-23-2014
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Quote:
Originally Posted by monilode View Post
42 year old woman comes to the physician because of a 4 month history of fatigue, palpitations and anxiety. She has had 3 kg ( 7 lb) weight loss during this period. She has also noted heat intolerance and increasing frequency of bowel movements. She has a 10 year history of asthma well controlled with inhaled albuterol .Her temperature is 37 C ( 98.6 F ) , pulse is 110/min and regular and blood pressure is 150/70 mm Hg. Examination shows lid lag and exophthalmos. The thyroid gland is large and non-tender, a thyroid bruit is heard. Deep tendon reflexes are normal. Serum studies show and thyroid stimulating hormone concentration of less than 0.1 U/ml and thyroxine (T4) concentration of 16U/ml. A thyroid scan shows a diffuse increased uptake. Which of the following is the most appropriate initial step in management.
A) Intravenous cortisol therapy
B) Intravenous sodium iodide therapy
C) Oral 131 therapy
D) Oral propylthiouracil therapy
E) Oral terazosin
F) Subtotal thyroidectomy
It is D, PTU. Bblockers (Propanolol) are often also used as a first line agent for thyroid storm. A, is incorrect, but likely the second best answer. Steroids are helpful in thyroid storm but an antithyroid agent like PTU that also reduces the conversion of peripheral T4/T3 is needed. C is a tempting wrong answer. 131 therapy is the most reasonable curative option, as total thyroidectomy and lifelong methimizole are not as efficacious however, there are two problems with picking this answer, one, you don't use it in an acute setting, this patient has elevated HR is in distress etc, the question asks "INITIAL" step. Second, severe opthalmopathy, "Examination shows lid lag and exophthalmos" is a relative C/I for I-131 therapy because it is known to exacerbate opthalmic damage.

Take home points for the question: PTU, Propanolol should be the first things to reach for when treating Thyroid Storm. Steroids have some role but are a second choice. Do not use I-131 as an "INITIAL" step, and be careful if they have eye problems.

Extra credit: use PTU only in the first trimester of pregnancy and thyroid storm, otherwise methimizole is your better choice. Also, know the AE of both of these drugs. I think in addition to Agranulocytosis methimizole can cause cutis aplasia or some other skin manifestation and PTU causes hepatic problems. Look these up since i'm not sure, they're both pretty high yield.
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The above post was thanked by:
AKhan01 (12-14-2015), Giek (11-18-2014), monilode (08-23-2014)
  #3  
Old 08-23-2014
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Thanks 2cool4medschool. Very very helpful ! Thanks for the detailed explanation for each option .
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