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Rhaffy B. Rapacon

Med III

Case Protocol

DATA:

A 45 year-old woman was seen in the emergency room at this hospital because of a mass in the

neck.

HISTORY OF PRESENT ILLNESS

The patient had been well until 2.5mo before presentation, when she noted a mass in

the right side of her neck and felt a lump in her throat when swallowing. She was seen by her

primary care physician. She had a history of mitral valve with regurgitation, cardiac arrhythmias

(atrial premature complexes and ventricular premature contractions), ovarian cysts and

anxiety. She had a total hysterectomy and right salphingo-oopherectomy for uterine fibroids.

She drank alcohol in moderation and did not smoke or use illicit drugs. Medications included

atenolol, lisinopril, fluoxetine, calcium carbonate, a multivitamin and amoxicillin before dentalwork. She had no known allergies. She was married, had no children, and work in an office. Her

father had hypothyroidism, an aunt had a goiter and a sister had an unspecified thyroid her

other siblings are healthy.

On examination, the blood pressure was 128/74mmhg, the pulse 66 beats/min, weight

66.7kg and height 165.1 cm. a nodule was palpable in the thyroid on the right side. There was

no palpable lymphadenopathy. A grade 2/6 systolic murmur was heard at the apex. The

remainder of examination was normal.

Blood level of thyrotropin was 1.74mu/ml (RF: 0.40-5.00). ultrasonography of thyroid

gland reveal gland reveal a heterogenous, hypoechoic nodule (42mm by 32mm by 26mm) in

the midpole of right lobe. The nodule had lobulated margins, scattered central calcifications

and mild central blood flow. A solid hypoechoic nodule (24mm by 19mm by 34mm), posterior

and inferior to the first nodule, contained several foci of of punctute calcifications. An enlarged

lymph node in lower cervical region (level 4) on the right side of the neck had abnormal internal

architecture and contained macrocalcifications.

The patient was referred to the department of adult medicine at this hospital. She

reported a mild cough productive of yellow phlegm, occasional palpitations and a timbre of her

voice at a lower that was lower than usual, which she attributed to a recent respiratory

infection. She had no history of radiation to the head or neck. Vital signs were normal. A firmmass (40mm in greatest dimension) and a smaller nodule (inferoposterioyr to the first) were

palpated in the right lobe of thyroid. A single palpable nodule was nearby. The remainder of

examination was normal. UTZ of thyroid in the clinic revealed two solid, heterogenous thyroid

nodues with irregular border in the right lobe, calcifications in the larger nodule and cervical

lymphadenopathy, including a node adjacent to larger nodule.

A diagnostic procedure was performed.

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Differential Diagnosis:

Infective endocarditis

Thyroid goiter

Thyroid Cancer

I consider infective endocarditis as may differential diagnosis because the patients are

manifesting signs and symptoms of it like mitral valve with regurgitation, grade 2/6 systolic

murmur that was heard in the apex. Recurrent upper respiratory infection can also add up to mysuspicion of infective endocarditis. I ruled it out because patient does not manifest the two

pathognomonic signs and symptoms of infective endocarditis tender subcutaneous nodules found

on the distals pads of the digits (osler nodes) and non-tender maculae on the palms and sole (

janeway lesions).

I consider thyroid goiter as my differential diagnosis, because goiter is an enlargement of

the thyroid gland it can be also palpated as a nodule. Because the patient has a strong family

history of thyroid disease it can add up to my suspicion of thyroid goiter. I ruled it out because

goiter can be palpated as one nodule during acute manifestation and not a multiple one. Usually

the level of the thyrotropin level in goiter is high, but in my patient it is normal. Nodular disease ischaracterized by the disordered growth of thyroid cells, often combined with the gradual

development of fibrosis. Because the management of goiter depends on the etiology, the

detection of thyroid enlargement on physical examination should prompt further evaluation to

identify its cause.

I consider thyroid cancer because the ultrasound of the patient highly suggestive of

thyroid disease. Thyroid carcinoma is the most common malignancy of the endocrine system.

Malignant tumors derived from the follicular epithelium are classified according to histologic

features. Thyroid cancer is twice as common in women as men, but male sex is associated with a

worse prognosis. My final diagnosis is papillary thyroid cancer it accounts 7090% of well-

differentiated thyroid malignancies. Characteristic cytologic features of PTC help make the

diagnosis by FNA or after surgical resection; these include psammoma bodies, cleaved nuclei with

an "orphan-Annie" appearance caused by large nucleoli, and the formation of papillary structures.

It ismultifocal and to invade locally within the thyroid gland as well as through the thyroid capsule

and into adjacent structures in the neck. It has a propensity to spread via the lymphatic system but

can metastasize hematogenously as well, particularly to bone and lung. Because of the relatively

slow growth of the tumor, a significant burden of pulmonary metastases may accumulate,

sometimes with remarkably few symptoms. Which is the reason why patient are manifesting signs

and symptoms of respiratory diseases.

Diagnostic:Fine needle biopsyto assess if the mass is metastatic or not.

Reference: Harrisons Principle of Internal Medicine 7th

ed.