A 10-year-old girl is brought to the office by her father due to concerns about her behavior and declining school performance over the last 6 months. Her teachers have said that she is constantly distracted and does not pay attention in class. The patient's grades have dropped significantly and she is failing most of her classes. In addition, she has been irritable and moody with frequent outbursts of crying recently. She takes no daily medications or supplements. Temperature is 36.7 C (98 F), blood pressure is 116/58 mm Hg, and pulse is 114/min. Weight is 27 kg (59.5 lb), decreased by 1 kg (2.2 lb) from last year. Physical examination reveals a nervous-appearing girl who is fidgeting with her clothes. The pupils are equally reactive to light. The sclera is nonicteric and visible above the iris. Cardiac examination reveals a regular rhythm and normal S1 and S2. The abdomen is soft and nontender without hepatosplenomegaly. Deep tendon reflexes are 3+ and symmetric in the upper and lower extremities. The skin is warm and moist. Without treatment, this patient is at risk of developing which of the following long-term complications?

Question

A 10-year-old girl is brought to the office by her father due to concerns about her behavior and declining school performance over the last 6 months.  Her teachers have said that she is constantly distracted and does not pay attention in class.  The patient's grades have dropped significantly and she is failing most of her classes.  In addition, she has been irritable and moody with frequent outbursts of crying recently.  She takes no daily medications or supplements.  Temperature is 36.7 C (98 F), blood pressure is 116/58 mm Hg, and pulse is 114/min.  Weight is 27 kg (59.5 lb), decreased by 1 kg (2.2 lb) from last year.  Physical examination reveals a nervous-appearing girl who is fidgeting with her clothes.  The pupils are equally reactive to light.  The sclera is nonicteric and visible above the iris.  Cardiac examination reveals a regular rhythm and normal S1 and S2.  The abdomen is soft and nontender without hepatosplenomegaly.  Deep tendon reflexes are 3+ and symmetric in the upper and lower extremities.  The skin is warm and moist.  Without treatment, this patient is at risk of developing which of the following long-term complications?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beca_6c22_8f63_b3885163e977_MD0005_00 This patient has behavioral changes, weight loss, lid lag, and increased cardiac output, concerning for hyperthyroidism. Graves disease (an autoimmune condition in which TSH receptor-stimulating antibodies activate the TSH receptor) is the most common etiology. Hyperstimulation of the TSH receptor causes elevated T3 and T4 levels. Excess circulating T3 and T4 hormones result in a constellation of findings related to sympathetic overactivity. Children and adolescents with hyperthyroidism often have psychological changes, such as inattention, moodiness/irritability, and poor school performance. Other calorigenic sequelae include weight loss, tachycardia with a wide pulse pressure, hyperreflexia, and warm/sweaty skin. A diffuse goiter is often present, and patients typically have lid lag, which causes the sclera to be visible above the iris. Exophthalmos (proptosis due to extraocular muscle inflammation) is common in adults. If hyperthyroidism remains untreated, increased adrenergic activity stimulates cardiac contractility, which can lead to arrhythmias (eg, atrial fibrillation) and dilated cardiomyopathy. Osteoporosis is a long-term complication due to elevated thyroid hormone stimulating calcium and phosphate release from bone. (Choice A) Mitral valve prolapse and regurgitation, not mitral valve stenosis, are associated with hyperthyroidism. (Choice B) Nephropathy is a complication of untreated diabetes mellitus, which typically presents with polydipsia, polyuria, and weight loss. Although behavioral changes may occur, lid lag and hyperreflexia would not be expected. (Choice D) Respiratory insufficiency can occur with myopathies such as myasthenia gravis. Ocular muscle weakness is typical, but a myopathy would result in hyporeflexia, not hyperreflexia as seen in this patient. (Choice E) In times of stress, untreated adrenal insufficiency can lead to hypotension and shock. Although presentation may include behavioral changes and weight loss, this disorder is unlikely to cause hyperreflexia or lid lag. Educational objective: Hyperthyroidism is characterized by sympathetic overactivity and can present with psychological changes (eg, irritability, poor academic performance) in addition to weight loss, tachycardia, hyperreflexia, and lid lag. Treatment prevents complications such as arrhythmias, cardiomyopathy, and osteoporosis. References: The influence of thyroid dysfunction on bone metabolism. (http://www.ncbi.nlm.nih.gov/pubmed/25648501) Metabolic and clinical consequences of hyperthyroidism on bone density. (http://www.ncbi.nlm.nih.gov/pubmed/23970897)

A 10-Year-Old Girl Is Brought to the Office by Her