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Old 10-17-2011
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Thyroid Severe Leg Cramps and High TSH!

A 45-year-old man complains of severe cramps in his legs for the past 30 days. He previously has been healthy with no complaints. He takes no medications, denies drug use, and rarely consumes alcohol. He has no chest pain or shortness of breath. When specifically questioned, he reports that he has been feeling increasingly fatigued. On examination, he appears lethargic. His vital signs are stable. Lungs are clear. Cardiac examination is unremarkable. His muscle strength is intact. Laboratory studies show a normal hematocrit, an elevated thyroid-stimulating hormone level, and normal T3 and T4 levels. Which of the following is the most appropriate management?

A. Methimazole therapy
B. Observation
C. Radioactive iodine therapy
D. Thyroidectomy
E. Thyroxine therapy
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Old 10-17-2011
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thyroxin ?????
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Old 10-17-2011
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Correct Answer Answer

The correct answer is E. The patient is hypothyroid as shown by the elevated thyroid-stimulating hormone (TSH). If his T3 and T4 were diminished also, this diagnosis would have been certain. If he were asymptomatic and had normal T3 and T4 levels, then he would have subclinical hypothyroidism. He has normal T3 and T4 but is symptomatic with leg cramps and lethargy. This should be treated with thyroxine, and the TSH level should be rechecked in 6 weeks.
Methimazole (choice A) would be used in treating hyperthyroidism. Agranulocytosis is a possible adverse side effect.
Observation (choice B) would be appropriate if the patient had subclinical hypothyroidism.
Radioactive iodine therapy (choice C) would be used for the treatment of Graves disease.
Surgery would have no role in the initial management of hypothyroidism (choice D).
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Old 10-17-2011
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I have a question and it might sound stupid but please bear with me. How can a guy with normal t3 and t4 levels actually have symptoms of hypothyroidism? The thing is that the problems of hypothyroidism is due to a decrease in the T3 and T4 lvl which arent seen here.TSH while is indicative of a primary throid problem doesnt have anything to do with the symptoms.

I ask this as on reading the question i also figured he was probably hypothyroid from the symptoms and from the high TSH . But since the lvl of t3 and t4 are normal i got confused and counld figure out a how a person can be hypothyroid bt still have normal values.
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Old 10-17-2011
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Idea!

Question doesn't mention Free levels of T4 and T3... So unless specified these levels are considered total T3 and T4 and so, TSH and symptoms are the only criteria you have to rely on... Hope it helps...
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