WBR1142

Author	[[PageAuthor::Pratik Bahekar, MBBS [1]]]
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Endocrine
Prompt	[[Prompt::On examination physician notices a horizontal scar in front of the neck. His vitals are as follows, BP 138/88 mm of Hg Pulse 98b/m Temperature 99F His systemic examination is otherwise normal, except hypereflexia in all four extremities. What is the next best step in the management of osteoporosis?]]
Answer A	AnswerA::Reduce dose of Levothyroxine
Answer A Explanation	[[AnswerAExp::Obtimal doses of thyroxine is adjusted by regular monitoring of TSH. The patient is suffering from difficulty concentrating, fatigue, frequent bowel movements, heat intolerance, increased appetite, increased sweating, nervousness, restlessness and insomnia, from last 8 months. Which is indicative of excess thyroxine dose. Thyroxine activates osteoclasts, which results in osteoporosis. Vertebral fracture is one of the most common manifestation of osteoporosis. Therefore the next step in the management of osteoporosis in this patient should be reduction of levothyroxine.]]
Answer B	AnswerB::Tropical estrogen cream on vertebra
Answer B Explanation	AnswerBExp::Tropical estrogen cream on vertebra is not a treatment of osteoporosis. Hormone replacement therapy in post menopausal women tends to reduce incidence of osteoporosis. However, osteoporosis is not an indication for hormone replacement therapy.
Answer C	AnswerC::Advise to exercise in morning sunlight
Answer C Explanation	AnswerCExp::Morning sunlight may promote vit D synthesis, and is recommended in osteoporosis. However levothyroxine dose reduction is the indicated in this patient.
Answer D	AnswerD::IM testosterone once a month
Answer D Explanation	AnswerDExp::IM testosterone may promote bone formation. However the levothyroxine dose reduction is the indicated in this patient.
Answer E	AnswerE::Refer to an orthopedic surgeon
Answer E Explanation	AnswerEExp::Usually a referral is not a right answer in the USMLE. Referrals to an orthopedic surgeon may be indicated if the vertebral fracture causes spinal nerve entrapment .
Right Answer	RightAnswer::A
Explanation	[[Explanation::Thyroxine activates osteoclasts, which results in osteoporosis. Therefore the next step in the management of osteoporosis in this patient should be reduction of levothyroxine. Educational Objective: References: http://www.wikidoc.org/index.php/Hyperthyroidism_pathophysiology http://www.ncbi.nlm.nih.gov/pubmed/24570805]]
Approved	Approved::No
Keyword	WBRKeyword::Hyperthyroidism
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::