A 28-year-old woman comes to the office for a preventive visit. She is getting married in a few weeks and has been increasingly anxious due to last-minute details and preparation. For the past 3 weeks, the patient has had difficulty falling and remaining asleep as she is "too excited about the wedding." She notes that her dress required alterations and is pleased she "didn't have to go on a diet." She states that anxiety has not been an issue for her in the past and asks if there is a medication that could help her feel more relaxed and get some sleep. Medical history is insignificant; the patient takes no medications or supplements. She drinks alcohol infrequently on social occasions and does not use illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, pulse is 100/min and regular, and respirations are 16/min. Physical examination shows mild hand tremors with sweaty palms and is otherwise normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 28-year-old woman comes to the office for a preventive visit.  She is getting married in a few weeks and has been increasingly anxious due to last-minute details and preparation.  For the past 3 weeks, the patient has had difficulty falling and remaining asleep as she is "too excited about the wedding."  She notes that her dress required alterations and is pleased she "didn't have to go on a diet."  She states that anxiety has not been an issue for her in the past and asks if there is a medication that could help her feel more relaxed and get some sleep.  Medical history is insignificant; the patient takes no medications or supplements.  She drinks alcohol infrequently on social occasions and does not use illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, pulse is 100/min and regular, and respirations are 16/min.  Physical examination shows mild hand tremors with sweaty palms and is otherwise normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's anxiety, sleep disturbances, weight loss, tremors, sweating, and increased heart rate are consistent with hyperthyroidism. The first step in evaluating hyperthyroidism is measurement of serum TSH, which is low in patients with primary hyperthyroidism. Many different disorders cause hyperthyroidism (most commonly Graves disease), and diagnosis of the underlying etiology is necessary for appropriate treatment. Differentiating hyperthyroidism from anxiety disorders can be difficult due to overlap in symptoms (eg, anxiety, insomnia, sweating, palpitations). Some causes of hyperthyroidism (eg, postpartum and painless thyroiditis) can present with minimal or no thyroid enlargement on examination, making it more challenging to diagnose a thyroid disorder. Signs and symptoms associated with thyroid dysfunction rather than anxiety disorders include unintentional/unexplained weight loss (as in this patient), new-onset atrial fibrillation, hypertension, lid lag, and menstrual changes. To avoid misdiagnosis and inappropriate treatment, it is important to assess thyroid functioning in patients with new-onset anxiety symptoms and associated physical symptoms. (Choice A) A serum chemistry would not be warranted as the patient does not report symptoms or have physical examination findings that would suggest electrolyte disturbances or kidney dysfunction. Her constellation of symptoms is more consistent with hyperthyroidism. (Choices C, D, E, F, and G) Measurement of thyroid functioning is necessary before considering psychotherapy and/or psychotropic medication given this patient's unintentional weight loss and other symptoms suggestive of hyperthyroidism. Educational objective: Hyperthyroidism and anxiety disorders have considerable symptom overlap, including sleep disturbances, palpitations, and sweating. Measurement of thyroid functioning is the first step in management of patients with new-onset anxiety and physical symptoms to prevent misdiagnosis and provide appropriate treatment. References: Hyperthyroidism: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26926973)

A 28-Year-Old Woman Comes to the Office for a Preventive