<prompt> A 19 year old female presents with pain in the neck for 5 days. She is not able to wear tie for her job because of neck pain. HO fatigue and lethargy for 10 days. She had flu like symptoms 20 days ago which resolved spontaneously. BP 11080 mmHg, Pulse 48min. Extremities are cold and dry. Neck is very tender. ECG normal. TSH is elevated. ESR 30 mmhr. Next appropriate stepAtropine injectionLevothyroxine administrationAspirinIncrease iodine intake in food  <response>: Answer: c Aspirin SCHWARTZ 19TH ED, P-1525; SABISTON 19TH ED, P-895Granulomatous or Subacute or De Quervains thyroiditisMost commonly occurs in 30- 40 year-old womenStrong association with the HLA-B35Fever with Sudden or gradual onset of neck painHo preceding URI; Viral etiologyGland - enlarged, tender, firmClassically progresses through four stages: Hyperthyroid-Euthyroid-Hypothyroid-EuthyroidA few patients develop recurrent diseaseEarly stages: ESR, Tg, T4, and T3 levels are elevated, TSH decreasedDuring Hypothyroid stage: elevated TSHLow radio-iodine uptakeFNAC - multinucleated giant cells of an epithelioid foreign body type and aggregates of lymphocytes activated macrophages, and plasma cellsSelf-limiting diseaseAspirin and NSAIDs are used for pain reliefPrednisolone for severe casesShort-term thyroid replacement may be needed and may shorten the duration of symptoms 