186) A 65 year old woman is evaluated in your office for lower extremity swelling and weakness. She has difficulty speaking for the past 3 months. Her past medical history is significant for renal insufficiency and hypertension that was diagnosed 6 months ago. A TSH level that was obtained 3 weeks ago was normal. She smokes cigarettes, about 1 pack per day for the past 35 years. Her medications include Lisinopril and Hydrochlorthiazide. On physical examination, her heart rate and rhythm are regular. Lungs are clear to auscultation. She has gross edema of the lower extremities. There is no extremity weakness. Head and neck examination reveals findings as shown below:

Most appropriate next step in management of this patient:

A) Stop Lisinopril

B) Start Levothyroxine

C) Intubation

D) Abdominal fat pad biopsy

E) Serum immunoelectrophoresis