A 20-year-old student came to the emergency department with primary complaints of palpitations, low-grade fever, and anxiety for 2 months. She reports that she is irritable and suffers severe moo d swings that is interfering with her sleep and relationships (she admits to crying spells and frequent fights with friends and family). She has also lost 12 pounds in the past 2 months with no apparent alteration in her diet or physical activity (though she is happy with her weight loss). She denies any past medical problems, though her friends have always been worried that she eats too little.
Her temperature is 38.0 C (100.4 F), blood pressure is 148/62 mm Hg, pulse is 122/min and regular, and respiratory rate is 28/min. Examination reveals a bruit heard over the anterior neck, fine tremor of the hands, and warm, moist skin. Her eyes and eyelids do not move together during finger following test (with steady head). Laboratory work is sent, including a thyroid panel, but will not be available until tomorrow morning.
Which of the following is the most appropriate initial management at this time?
- Diltiazem therapy
- Iodine therapy
- Methimazole therapy
- Propranolol therapy
- Referral to a surgeon
Answer(s): D
Explanation:
This patient had hyperthyroidism, though the exact cause of her condition is not currently clear. The immediate treatment should focus on controlling the patient’s symptoms for which a non-specific beta-blocker is seemingly an ideal choice. Propranolol therapy can be initiated without any adverse effects while the patient undergoes further workup of her condition. As the treatment for hyperthyroidism varies depending upon the cause of the condition, more definitive therapy should be avoided. Diltiazem (choice A) helps control heart rate but does not have the same antiadrenegenic properties as beta-blockers/ The initial treatment for symptomatic hyperthyroidism is propranolol. Iodine (choice B) can be used in high doses to inhibit thyroid production of T3 and T4. Until it’s clear that this patient does not have an exogenous source of thyroid hormone (and until it is clear she is not pregnant), this agent should not be considered. Propylthiouracil (PTU) and Methimazole (choice C) inhibit the organification of iodine to tyrosine residues. If this patient has Graves diseases, this would be an appropriate treatment. Until a diagnosis is made, however, initial therapy should consist of a beta- blocker. Surgical treatment (choice E) of hyperthyroidism is often a reasonable treatment for patients who cannot tolerate medical therapy of radioactive iodine ablation.
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