Endocrinology Case

Buyucan, K.Cueto, M.

Cunanan, S.Dadgardoust, P.

Daguman, E.Dator, D.

General Data

• FP• Female• 53 year old• Tondo, Manila

Chief Complaint

• Hoarseness of voice

History of Present Illness15 months PTA: Hoarseness of Voice X-ray showed PTB with fibrotic component on both upper lung fields Unrecalled medication-did not afford relief

11 months PTA: Mass on the left side of her neck Persistence of her previous symptom No consult No medication taken

9 months PTA: Persistence of symptoms prompted consult where

TSH levels and ultrasound conducted Patient was advised surgery but deferred Took herbal medicines reported gave slight relief of

symptoms.

History of Present Illness

1 month PTA: Persistence of symptom and presence of mass on left side of neck prompted consult at a private clinic Referred to an ENT where laryngoscopy was done She was again advised surgery

Admission

Past Medical History

• Previous Hospitalizations: none• Major childhood illnesses: none• Major adult illness: minimal PTB, hypertension• Immunizations: unrecalled

Past Medical History

• Medication:Therabloc 25 mg 1 tab every morningMeloxicam 15 mg 1 tab once a dayCaltrate Plus once a dayParacetamol 1 tab q 8 hours PRN for

mild to moderate painSulidin gel apply to affected area PRN for

pain• Adverse drug reactions: none

OB-Gyne History

• G9P8 (9017) via NSD: No complications, no transfusions

• Menarche: 15yo• Menstrual Interval: irregular• Duration: 3-6 days• Amount: 3 pads/day, moderately-soaked• Symptoms: (-) dysmenorrhea, (-) headache

Family History

• (+) cancer(sibling)• (-) PTB• (-) diabetes• (-) hypertension• (-) stroke• (-) allergies• (-) asthma• (-) heart disease

Personal History

• Diet: mixed diet of meat and vegetables• Non-smoker• Non-alcoholic beverage drinker• Denies illicit drug use• Does not exercise regularly

Review of Systems• General: (-) weight loss(-) loss of consciousness

Specific organ/ System Symptom Review

Skin (-) pallor, (-) itchiness, (-) rashes, (-) pruritus, (-) jaundice, (-) alopecia, (-) paronychia

Eyes (-) eye pain, redness, (-) eye discharge, (-) itchiness

Ears (-) impairment of hearing, (-) aural discharge, (-) tinnitus

Nose (-) epistaxis, (-) nasal obstruction

Mouth (-) oral ulcers, (-) bleeding gums, (-) toothaches , (-) dentures

Throat (-) soreness, (-) tonsillitis

Neck see HPI

Breast (-) palpable breast masses, (-) nipple discharge, (-) tenderness, (-) breast enlargement

Cardiovascular (+) palpitations, (-) chest pains, (-) PND, (-) orthopnea

Review of SystemsSpecific organ/ System Symptom Review

Respiratory (-) cough, (-) dyspnea, (-) wheezing, (-) hemoptysis

Gastrointestinal (-) epigastric pain, (-) hematochezia, (-) melena, (-) diarrhea, (-) constipation

Genitourinary (-) suprapubic pain, (-) stress incontinence, (-) frequency, (-) dysuria, (-) hematuria, (-) flank pain, (-) hesitancy, (-) nocturia

Musculoskeltal (-) joint stiffness, pain, swelling, (-) muscle pain

Endocrine (-) heat-cold intolerance,(-) tremors, (-) polyphagia, polydipsia, polyuria

Hematopoeitic (-) easy bruisability, (-) abnormal bleeding

Neurologic (-) seizures, (-) insomnia, (-) behavioral changes, (-) memory loss

Psychiatric (-) depression, (-) illusion, (-) delusion, (-) hallucinations

Physical ExamGeneral Survey: conscious, coherent,

ambulatory Vital signs: • BP: 110/60mmHg• PR 120bpm, regular• RR 30cpm• T 39.0 0C • Ht: 152 cm, Wt: 52 kgs

Physical ExamSkin• Warm, dry skin, no active dermatoses, (-) alopecia (-)

rashes (-) spider angiomataHead • No gross head deformity, no gross facial asymmetry• Pink palpebral conjunctivae, anicteric sclera, no

ptosis• No nasoaural discharge, turbinates congested• Moist buccal mucosa, nonhyperemic posterior

pharyngeal wall, tonsils not enlarged, uvula midline

Physical ExamNeck• Supple neck, (-) parotid enlargement, trachea midline,

(-) palpable cervical LN • (+) Left Anterior neck mass• JVP of 3cm at 45 degree angle, carotid pulse rapid

upstroke, gradual downstroke, no carotid bruits • Neck mobility not rigid, non palpable lymph nodesRespiratory• Symmetrical chest expansion, no intercostal

retractions• unimpaired tactile and vocal fremiti on both lung fields• resonant on percussion• clear breath sounds, no wheezes, crackles

Physical ExamCardiovascular• Adynamic precordium, AB 4th LICS MCL, (-) heaves,

thrills and lift, S1>S2 at the apex, • S2>S1 at the base, (-) murmursAbdomen• Flabby abdomen, (+) striae• normoactive bowel sounds, tympanitic on all

quadrants, no obliteration of the Traube space, (-) hepatomegaly liver,

• (-) tenderness, (-) fluid wave• no masses, no tenderness

Physical ExamExtremities• Pulses full and equal on all extremities

PATHOPHYSIOLOGY

Non-toxic Goiter

• varies with the etiology and duration of the goiter

• uniform follicular epithelial hyperplasia (diffuse goiter) thyroid architecture loses its uniformity with development of areas of involution or fibrosis interspersed with areas of focal hyperplasia multinodular goiter (MNG)

Non-toxic Goiter

• many diffusely enlarged goiters are composed of multiple soft nodules which cannot be palpated individually

• accumulation of colloid may also contribute to the nodularity of the goiter

• hemorrhage or cystic degeneration of a hyperplastic nodule sudden focal increase in size of a goiter

Non-toxic Goiter

• in areas of growth, regression and hemorrhage, irregular calcifications can occur

• the evolution of this multinodular stage is accompanied by the development of "hot" (hyper-functioning) and "cold" (non-functional) nodules on thyroid nuclear scan with functional autonomy

Non-toxic Goiter

• nodules within a MNG are due to a combination of monoclonal and polyclonal expansion and correlates with the development of functional autonomy and reduction in TSH levels

• the natural history for goiters is a continuous accumulation of multiple autonomously functioning, or "hot" nodules leading to mild thyrotoxicosis after several decades (developing into a toxic MNG)

Laboratory Tests and Work-ups

(Pre-Op)

Thyroid Function Test

Analyte Results Reference Value

FT3 2.56 1.45-3.48 pg/ml

FT4 1.17 0.71-1.85 ng/dl

TSH 0.260 0.47-4.64 UIU/ml

Thyroid Ultrasound

• Showed both thyroid glands to be enlarged• R lobe: 5.8 x 1.3 x 1.3 cm• L lobe: 6.1 x 2.4 x 2.4 cm• Impression: – Bilateral Thyromegaly

Thyroid Scintigraphy• Px was given an oral dose of 1.9 MBq of 131-I, then uptake

measurements were taken at 4 and 24 hours• R lobe: 5.1 x 2.2• L lobe: 4.8 x 3.3• The R lobe showed fairly homogenous radiotracer

distribution with no definite labeling defect. • The L lobe showed non-uniform tracer localization with an

area of diminished uptake in its lateral aspect corresponding to a clinically palpable nodule

• Impression– Bilobed Thyromegaly– Large cold nodule, L lobe

(Post-Op)

Thyroid Hormone

• Thyroxine should be administered to ensure that the px remains euthyroid

• TSH suppression

Thyroglobulin

• Tg levels of Pxs who have undergone total thyroidectomy should be below 2 ng/ml when px is taking T4 and below 5 ng/ml when px is hypothyroid

• Tg and antiTg Ab levels should be measured initially for 6 months then annually

Management and Treatment

Post-operative Pain Management

• NSAIDs (Meloxicam)– Taken as needed for moderate to severe pain (5-7 days post-op)

• Paracetamol– taken as needed for mild to moderate pain

• Levothyroxine 100mcg/day– Lifetime supplementation of thyroid hormones for

maintenance because the patient undergone total thyroidectomy

• Calcium supplements- Calcium levels usually go down post-operatively