{"id":1897,"date":"2024-02-28T14:21:00","date_gmt":"2024-02-28T14:21:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=1897"},"modified":"2025-10-01T11:39:32","modified_gmt":"2025-10-01T19:39:32","slug":"usmle-step-2-question-of-the-day-thyroid-management","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Thyroid management"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#A_Refer_for_thyroidectomy\" >A. Refer for thyroidectomy<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#B_Administer_propylthiouracil_PTU\" >B. Administer propylthiouracil (PTU)<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#C_Administer_oral_glucocorticoids\" >C. Administer oral glucocorticoids<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#D_Refer_the_patient_for_radioactive_iodine_ablation\" >D. Refer the patient for radioactive iodine ablation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#E_Selenium\" >E. Selenium<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-10\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!\u00a0Today&#8217;s case involves a 35-year-old woman presents with unintentional weight loss, diarrhea, and proptosis. Vital signs show an elevated pulse and blood pressure. Lab results indicate low TSH, high free T4, and positive thyroid-stimulating immunoglobulin. What&#8217;s the best next step in management? Do you know the answer? Let&#8217;s find out!<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 35-year-old woman presents to the primary care clinic due to unintentional weight loss, diarrhea, excessive sweating, and occasional diplopia. Past medical history is unremarkable. Temperature is 37.4\u00b0C (99.3\u00b0F), blood pressure is 152\/78 mmHg, pulse is 120\/min, respiratory rate is 18\/min, and oxygen saturation is 98% on room air. On physical examination, her thyroid gland is diffusely enlarged without nodules and non-tender, and her eyes exhibit significant proptosis with restrictive extraocular movements. Laboratory tests reveal a decreased thyroid-stimulating hormone (TSH) level, elevated free thyroxine (T4) level, and positive thyroid-stimulating immunoglobulin. Which of the following is the best next step in management?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Refer for thyroidectomy<\/strong><strong>B. Administer propylthiouracil (PTU<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Administer oral glucocorticoids<br><\/strong><br><strong>D. Refer the patient for radioactive iodine ablation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;<\/strong><strong>Selenium<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"A_Refer_for_thyroidectomy\"><\/span>A. Refer for thyroidectomy<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"B_Administer_propylthiouracil_PTU\"><\/span>B. Administer propylthiouracil (PTU)<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Propylthiouracil (PTU) is an antithyroid drug used in the treatment of hyperthyroidism. It is usually indicated in patients with mild hyperthyroidism, no orbitopathy, and a high likelihood of remission. In this patient with moderate ophthalmopathy, thyroidectomy is preferred.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"C_Administer_oral_glucocorticoids\"><\/span>C. Administer oral glucocorticoids<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Although oral glucocorticoids can be used in the management of Graves ophthalmopathy, they do not address the underlying hyperthyroidism and are usually used in combination with other therapies in patients with mild orbitopathy.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"D_Refer_the_patient_for_radioactive_iodine_ablation\"><\/span>D. Refer the patient for radioactive iodine ablation<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Radioactive iodine ablation is a common treatment for Graves disease but is contraindicated in patients with moderate to severe ophthalmopathy as it can worsen eye symptoms.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"E_Selenium\"><\/span>E. Selenium<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Selenium can be used in patients with mild orbitopathy in parts of the world where there is deficiency.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with classical symptoms of hyperthyroidism and a non-nodular thyroid in addition to positive thyroid-stimulating immunoglobulin, consistent with the diagnosis of Graves disease. Her ocular findings of proptosis and restricted extraocular movements with occasional diplopia are suggestive of moderate Graves ophthalmopathy, which is an indication for thyroidectomy.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Treatment options for Graves disease include antithyroid drugs, radioactive iodine ablation, and thyroidectomy. The choice of treatment depends on the patient&#8217;s symptoms, the severity of the disease, patient preferences, the presence of contraindications to therapy, and the presence of certain features like ophthalmopathy. Antithyroid medications like methimazole or propylthiouracil (PTU) inhibit the synthesis of thyroid hormones, providing a non-invasive, reversible treatment option. However, there is a high relapse rate with these medications once the medication is discontinued.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Radioactive iodine ablation offers a permanent solution by destroying the overactive thyroid tissue but often results in hypothyroidism, necessitating lifelong thyroid hormone replacement. Radioactive iodine treatment is contraindicated in pregnant or breastfeeding women and in patients with Graves&#8217; ophthalmopathy, as it can exacerbate the condition.&nbsp;Surgery (total or subtotal thyroidectomy) is typically reserved for patients with large goiters causing compressive symptoms, suspicion of malignancy, and moderate or severe ophthalmopathy. It&#8217;s also considered for those who are pregnant or cannot tolerate other treatment options. However, surgery carries risks, such as injury to the recurrent laryngeal nerves and parathyroid glands. &nbsp;glands. &nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"776\" height=\"650\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-11T082247.103.png\" alt=\"GRAVE'S DISEASE\n\nTreatment\/Adverse Effects\n\nAntithyroid Medications (Propylthiouracil, Carbimazole, Methimazole)\n- Allergic reaction\n- Agranulocytosis\nMethimazole\n- 1st trimester teratogen\n- Cholestasis\nPropylthiouracil\n-Hepatic failure\n-ANCA-associated vasculitis\n\nRadioactive Iodine Ablation\n- Permanent hypothyroidism\n- Worsening of ophthalmopathy\nContraindications:\n- Preganancy\n- Breastfeeding\n\nSurgery (Total or Subtotal Thyroidectomy)\n- Permanent hypothyroidism\n- Recurrent laryngeal nerve injury\n- Hypoparathyroidism\n\" class=\"wp-image-1899\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-11T082247.103.png 776w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-11T082247.103.png?resize=300,251 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-11T082247.103.png?resize=768,643 768w\" sizes=\"auto, (max-width: 776px) 100vw, 776px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Graves disease treatment options include antithyroid drugs, radioactive iodine ablation, and thyroidectomy. In patients with moderate to severe Graves ophthalmopathy, thyroidectomy is the preferred treatment.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis [published correction appears in Thyroid. 2017 Nov;27(11):1462]. Thyroid. 2016;26(10):1343-1421. doi:10.1089\/thy.2016.0229<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/create\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-11T082400.406.png\" alt=\"Ace your clerkships with clinical practice videos on Osmosis. Watch now.\" class=\"wp-image-1900\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-11T082400.406.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-11T082400.406.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more \u00a0USMLE\u00ae Step 2 CK practice questions?\u00a0Try Osmosis by Elsevier today! Access your\u00a0<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Assess clinical features and management strategies in a thyroid case presenting with hyperthyroidism and eye symptoms, highlighting key considerations in treatment choices. What&#8217;s the answer? Let&#8217;s find out!<\/p>\n","protected":false},"author":202,"featured_media":1898,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[27,20,1370,45],"tags":[449,1089,1090,1092,1096,1093,1094,1091,1095,671],"class_list":["post-1897","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-2-questions","category-step-2","tag-clinical-cases","tag-graves-disease","tag-hyperthyroidism","tag-ophthalmopathy","tag-propylthiouracil","tag-radioactive-iodine","tag-thyroid-management","tag-thyroidectomy","tag-usmle-exam-prep","tag-usmle-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Thyroid management - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Thyroid management - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Assess clinical features and management strategies in a thyroid case presenting with hyperthyroidism and eye symptoms, highlighting key considerations in treatment choices. 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Let&#039;s find out!\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2024-02-28T14:21:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-01T19:39:32+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/70.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Marina Horiates Kerekes, MD &amp; Team\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-thyroid-management\"},\"author\":{\"name\":\"Marina Horiates Kerekes, MD &amp; 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