A 25-year-old woman comes to the office because of jitteriness, frequent mood swings, and palpitations for the past 2 months. At times, her symptoms make her worry that she may be having a heart attack. The patient has no prior medical conditions. Temperature is 37 C (98.6 F), blood pressure is 120/82 mm Hg, pulse is 102/min, and respirations are 12/min. Examination shows warm, moist skin and a fine tremor of the fingers. Which of the following would most likely provide the fastest relief of this patient's symptoms?

Question

A 25-year-old woman comes to the office because of jitteriness, frequent mood swings, and palpitations for the past 2 months.  At times, her symptoms make her worry that she may be having a heart attack.  The patient has no prior medical conditions.  Temperature is 37 C (98.6 F), blood pressure is 120/82 mm Hg, pulse is 102/min, and respirations are 12/min.  Examination shows warm, moist skin and a fine tremor of the fingers.  Which of the following would most likely provide the fastest relief of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_3bba_ed1f_9249_5141314c1973_MD0001_00 This patient has signs and symptoms of thyrotoxicosis, including tremor, dysphoria, sweating, and tachycardia with palpitations. Hyperthyroidism is associated with upregulation of beta-adrenergic receptors and increased adrenergic tone, which is responsible for many of the associated clinical features. Beta-adrenergic antagonists (eg, propranolol) are indicated to alleviate the adrenergic symptoms of thyrotoxicosis and are usually prescribed early, while completing the diagnostic evaluation and initiating definitive management (eg, antithyroid medication, radioiodine ablation, thyroidectomy). Some beta-adrenergic antagonists (eg, propranolol) also reduce peripheral conversion of thyroxine (T4) to triiodothyronine (T3), although this effect is delayed. (Choice A) Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat anxiety or depression. This patient's anxiety and mood symptoms will likely resolve with treatment of the underlying condition (ie, thyrotoxicosis). Also, SSRIs typically require 2-4 weeks for a noticeable effect. (Choice B) Thioamides (eg, methimazole, propylthiouracil) reduce the production of thyroid hormone by inhibiting thyroperoxidase, the enzyme responsible for iodination of tyrosine residues in follicular colloid. Although these agents are indicated for the treatment of hyperthyroidism due to overproduction of thyroid hormone (eg, Graves disease), they produce clinical effects only after a few weeks. (Choice C) Prazosin is an alpha-1 adrenergic antagonist. Alpha-1 adrenergic receptors are present on the vasculature and induce vasoconstriction when stimulated. Blockade of these receptors would not alleviate the patient's palpitations and tremor. (Choice E) Radioactive iodine is used to treat a variety of hyperthyroid disorders, most commonly Graves disease, but it takes several weeks to be effective. In addition, it occasionally causes a paradoxical increase in thyroid hormone production early in treatment (jod-Basedow effect) and therefore should be administered with beta-adrenergic antagonists. Educational objective: Beta blockers provide rapid relief of the adrenergic-mediated symptoms of thyrotoxicosis and can be given while awaiting diagnostic evaluation and definitive management.

A 25-Year-Old Woman Comes to the Office Because of Jitteriness