endocrinology case buyucan, k. cueto, m. cunanan, s. dadgardoust, p. daguman, e. dator, d
TRANSCRIPT
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Endocrinology Case
Buyucan, K.Cueto, M.
Cunanan, S.Dadgardoust, P.
Daguman, E.Dator, D.
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General Data
• FP• Female• 53 year old• Tondo, Manila
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Chief Complaint
• Hoarseness of voice
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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.
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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
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Past Medical History
• Previous Hospitalizations: none• Major childhood illnesses: none• Major adult illness: minimal PTB, hypertension• Immunizations: unrecalled
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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
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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
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Family History
• (+) cancer(sibling)• (-) PTB• (-) diabetes• (-) hypertension• (-) stroke• (-) allergies• (-) asthma• (-) heart disease
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Personal History
• Diet: mixed diet of meat and vegetables• Non-smoker• Non-alcoholic beverage drinker• Denies illicit drug use• Does not exercise regularly
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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
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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
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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
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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
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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
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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
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Physical ExamExtremities• Pulses full and equal on all extremities
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PATHOPHYSIOLOGY
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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)
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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
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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
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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)
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Laboratory Tests and Work-ups
(Pre-Op)
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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
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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
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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
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(Post-Op)
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Thyroid Hormone
• Thyroxine should be administered to ensure that the px remains euthyroid
• TSH suppression
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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
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Management and Treatment
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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
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• 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