Clinical Vignette VI

• Which of the following is the most appropriate next step in management of this patient?

A 25-year-old female patient is evaluated in the clinic for several months of progressively worsening fatigue, unintentional weight gain of 15 lbs (6.8 kg), and feelings of mild depression. During the appointment, the patient also reports worsening muscle weakness, constipation, dry and brittle hair, cold intolerance, and irregular menses with her last menstrual period being approximately six weeks ago. She states that up until four months ago, she felt perfectly healthy. The patient denies a past history of any similar medical condition. She does not drink alcohol, smoke, chew tobacco, or use recreational drugs. She is currently in a monogamous relationship with the same male partner for the past four years and admits to rarely using protection.  The only medication she currently takes is prescribed oral contraceptive pills which she sometimes forgets to take. She has no known allergies. The remainder of her medical history, family history, and social history are unremarkable.  

On physical examination, temperature is 96.8°F (36.0°C), pulse rate is 68 beats/min, blood pressure is 115/70 mm Hg, respiration rate is 16/min, and oxygen saturation is 99% breathing ambient air. On palpation, the patient’s thyroid gland is non-tender, slightly enlarged without any appreciable nodules. The patient’s hair is dry and brittle. Her skin is cool, dry, and brittle. Neurologic examination reveals delayed deep tendon reflexes. The remainder of the physical examination is unremarkable.

• The initial test yielded a negative result which essentially rules out one medical condition. With that particular medical condition ruled out, which of the following is the most appropriate next step in management of this patient?

Given the lab testing result and clinical exam findings, which of the following is the most appropriate next step in management of this patient?

• The particular test obtained from the previous question yielded the following result:

Patient Lab Test Result                                Lab Value Reference Range

21 μU/mL (21 mU/L) (abnl)                  0.5 – 5.0 μU (0.5 – 5.0 mU/L)

Provided the available lab testing results and clinical exam findings, which of the following is the most appropriate next step in management of this patient?

• The particular test obtained from the previous question yielded the following result:

Patient Lab Test Result                                Lab Value Reference Range

0.55 ng/dL (7.1 pmol/L) (abnl)          0.9 – 2.3 ng/dL (12-30 pmol/L)             

• What is this patient’s the most likely diagnosis given the available lab testing results, clinical exam findings, and positive test results for anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies?