WBR0222
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| Author | [[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]] |
|---|---|
| Exam Type | ExamType::USMLE Step 3 |
| Main Category | MainCategory::Primary Care Office |
| Sub Category | SubCategory::Endocrine |
| Prompt | [[Prompt::55 year old women came for a routine health check up and she was found to have abnormal lipid profile. Her TSH level is 11 µU/ml (normal is 0.35-5 µU/ml) and her free T4 is 1ng/dl (normal is 0.8-1.8 ng/dl). She is asymptomatic and taking no medications. Family history is positive for hypothyroidism in mother. Her two siblings are normal. She denies smoking, alcohol and drugs. Her menstrual cycles are normal. Examination is normal and CBC, metabolic profile and lipid profile are within normal limits. Which is best next step in this patient management?]] |
| Answer A | AnswerA::Anti-thyroid peroxidase antibodies measurement |
| Answer A Explanation | AnswerAExp::'''Incorrect''' : Though the option of measurement of antithyroid antibodies is appropriate; any patient with TSH more than 10 is started on levothyroxine irrespective of their disease status. |
| Answer B | AnswerB::Start her on levothyroxine |
| Answer B Explanation | AnswerBExp::'''Correct''' : Patient with TSH more than 10 is started on levothyroxine irrespective of their disease status. |
| Answer C | [[AnswerC::Measurement of free T3]] |
| Answer C Explanation | [[AnswerCExp::Incorrect : T3 measurement is usually done when TSH and free T4 is low.]] |
| Answer D | AnswerD::Thyroglobulin measurement |
| Answer D Explanation | AnswerDExp::'''Incorrect''' : Thyroglobulin measurement is inappropriate in the management of hypothyroidism. |
| Answer E | AnswerE::Thyroid ultrasound |
| Answer E Explanation | [[AnswerEExp::Incorrect : Thyroid ultrasound would be useful if there is thyroid enlargement is present in order to monitor any change in size and look for dominant nodule(>1cm). Patient examination is normal and hence won’t be appropriate next step.]] |
| Right Answer | RightAnswer::B |
| Explanation | [[Explanation::The patient is a case of subclinical hypothyroidism where they have elevated TSH levels with normal free T4. Treatment in a case of subclinical hypothyroidism is started only in the presence of
1. Anti thyroid antibodies 2. Symptoms of hypothyroidism 3. Abnormal lipid profile 4. Ovulatory and menstrual dysfunction. When antithyroid antibodies are present with elevated TSH, there is high chance for the patient to become overtly hypothyroid. However, patient's with TSH more than 10 is started on levothyroxine irrespective of their disease status. |
| Approved | Approved::Yes |
| Keyword | |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |