View source for WBR1142

 {{WBRQuestion
|QuestionAuthor= {{PB}}
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Endocrine
|MainCategory=Internal medicine
|SubCategory=Endocrine
|MainCategory=Internal medicine
|SubCategory=Endocrine
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Endocrine
|MainCategory=Internal medicine
|SubCategory=Endocrine
|MainCategory=Internal medicine
|SubCategory=Endocrine
|MainCategory=Internal medicine
|SubCategory=Endocrine
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Endocrine
|Prompt=On examination physician notices a horizontal scar in front of the neck. His vitals are as follows,
BP 138/88 mm of Hg
Pulse 98b/m
Temperature 99F
His systemic examination is otherwise normal, except hypereflexia in all four extremities. What is the next best step in the management of osteoporosis?

|Explanation=Thyroxine activates osteoclasts, which results in osteoporosis.  Therefore the next step in the management of osteoporosis in this patient should be reduction of levothyroxine.
|AnswerA=Reduce dose of Levothyroxine


|AnswerAExp=Obtimal doses of thyroxine is adjusted by regular monitoring of TSH.  The patient is suffering from difficulty concentrating, fatigue, frequent bowel movements, heat intolerance, increased appetite, increased sweating, nervousness, restlessness and insomnia, from last 8 months.  Which is indicative of excess thyroxine dose.  Thyroxine activates osteoclasts, which results in osteoporosis.  Vertebral fracture is one of the most common manifestation of osteoporosis.  Therefore the next step in the management of osteoporosis in this patient should be reduction of levothyroxine.
|AnswerB=Tropical estrogen cream on vertebra

|AnswerBExp=Tropical estrogen cream on vertebra is not a treatment of osteoporosis.  Hormone replacement therapy in post menopausal women tends to reduce incidence of osteoporosis.  However, osteoporosis is not an indication for hormone replacement therapy.
|AnswerC=Advise to exercise in morning sunlight

|AnswerCExp=Morning sunlight may promote vit D synthesis, and is recommended in osteoporosis.  However levothyroxine dose reduction is the indicated in this patient.
|AnswerD=IM testosterone once a month

|AnswerDExp=IM testosterone may promote bone formation.  However the levothyroxine dose reduction is the indicated in this patient.
|AnswerE=Refer to an orthopedic surgeon
|AnswerEExp=Usually a referral is not a right answer in the USMLE.  Referrals to an orthopedic surgeon may be indicated if the vertebral fracture causes spinal nerve entrapment .  
|References=http://www.wikidoc.org/index.php/Hyperthyroidism_pathophysiology
http://www.ncbi.nlm.nih.gov/pubmed/24570805
|RightAnswer=A
|WBRKeyword=Hyperthyroidism, 
|Approved=No
}}