Thyroid Small Group Cases for Students 2012

8/2/2019 Thyroid Small Group Cases for Students 2012

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EndoRepro 2012 Small Group Cases - Thyroid

Case Discussion 1

A 57-year-old man returns to your clinic after you obtained a serum TSH level and an ultrasoundimaging study of his thyroid. Three days ago, the patient had presented to you for the first time

with a lump on the right side of his neck he had discovered about 1 month ago while shaving.He has been hoarse for a while, which he thought was because of allergies. He has no neckpain or difficulty swallowing. He has no history of externalirradiation of his head or neck and nofamily history of thyroid disease.

Physical examination of his neck reveals a solitary, very firm nodule in his right thyroid lobe,which measures 2 cm by 3 cm and does not move with swallowing. There is no evidence ofcervical lymphadenopathy. Pembertons sign is absent.

Laboratory Test: TSH 2.53 mU/L (normal range 0.5 to 5.5 mU/L)

Thyroid Ultrasound Report: The right lobe measures 5.4 x 3.4 x 2.9 cm and the left one 4.9 x

3.5 x 2.7 cm. A hypoechoic nodule of 2.9 x 2.5 x 1.9 cm is seen inthe lower pole of the right thyroid lobe. It has some intrinsicvascularity. Two nodules are seen in the upper pole measuring0.6 x 0.7 x 0.5 cm and 0.7 x 0.8 x 0.6 cm. In the left thyroid lobe ahypoechoic nodule is present which measures 0.4 x 0.5 x 0.4 cm.Recommend thyroid scintigraphy for further evaluation of thethyroid lesions.

The patient is not overly concerned about the mass but wants to know whether he really needsto undergo additional studies or tests?

Questions:

1. What is your suspicion with respect to the nodule based on the clinical and biochemicalinformation and the imaging study you obtained? Please, explain.

2. What is, most likely, the functional status of the dominant nodule? Please, explain.

3. What is your next step in evaluating the thyroid nodule(s) of this patient? Please,explain.

4. Does the likelihood of having or being diagnosed with a thyroid nodule differ amongsexes?

5. What would be the treatment in case the thyroid nodule was found to be a papillarythyroid carcinoma?

Beta rays


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Case Discussion 2

A 27-year-old woman, who has been generally healthy and very active all of her life, presentswith fatigue and unexplained weight gain despite loss of appetite. For the last several months,she feels cold all the time, has increasing difficulty to concentrate and has lost interest infinishing her doctoral thesis on The Impact of Energy Conservation on the Environment. Whileshe did not have a problem climbing a tree about two years ago, she has now some difficultieswalking up the stairs. Her menstrual periods have recently become irregular but a pregnancytest was negative. Her older sister, who was diagnosed with a low thyroid and is taking somethyroid medication, told her to see a doctor. She is somewhat depressed and comes to find outwhats wrong with me?

On physical examination, she is overweight and appears tired. Her BP is 105/85 mmHg, her

heart rate is 61 beats per minute and her temperature is 97.5 F. Her eyes are puffy and herhands and skin are cool. You palpate an enlarged and firm thyroid with a slightly irregularsurface and you find sluggish deep tendon reflexes with a delayed (hung up) relaxation phase.

Questions:

1. Given this young womans clinical signs and symptoms, what is the most likelydiagnosis?

2. What is the most likely cause of this patients condition based on her history andphysical findings?

3. What is the most sensitive laboratory test to confirm her diagnosis? What additional

laboratory tests are helpful? What results do you expect and why?4. How will you treat this patient?

5. Assuming that you treated her condition well and she becomes pregnant severalmonths later, would you have to make any adjustments to her treatment? Explain.

6. Enumerate the possible consequences if her condition was left untreated and shecontinued to deteriorate. How is this called?


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Case Discussion 3

A 43-year-old woman is complaining of nervousness and insomnia. She feels easily flying ofthe handle because of minor irritations. She is happy that she finally lost several pounds

despite having a very good appetite. While she felt always constipated, she now moves herbowels about twice a day. However, she experiences frequent palpitations and feels alwayshot. These symptoms started several months ago and were accompanied by grittiness in hereyes. Her eye problems have worsened over time and she now has the feeling as if her eyesare being pushed out of her head. She recently overheard a co-worker calling her the Pop-Eye. She has begun to notice occasional double vision. She smokes about a pack a day for thelast 15 years.

On examination, the patient appears restless. Her blood pressure is 135/60 mm Hg, her restingheart rate is 98 beats per minute and her temperature is 99.1 F. She has lid lag, bilateralproptosis and a restricted upward gaze of her left eye. Her thyroid is symmetrically enlargedand, on auscultation, a bruit is audible. A faint systolic ejection murmur is present. Her hands

are warm and moist and her skin is velvety in texture. Her deep tendon reflexes are brisk andshe has a fine tremor of her fingers.

Questions:

1. The cause of this patients hyperthyroidism can be determined on clinical grounds.What part of her presentation allows you to make this diagnosis and whichpathologic mechanisms are involved in its disease-specific development?

2. How can you treat her hyperthyroidism?

3. Untreated hyperthyroidism can decompensate into a life-threatening emergencyduring an intercurrent illness or a surgical emergency. How do such patients present

and what do you call this condition?4. What is the term used to describe the thyroid condition of an apparently euthyroid

patient whose TSH is suppressed while thyroid hormone levels are still within thenormal range? Does this condition increase the risk of other medical problems?

Thyrotoxic crisis

Delirium, liver failure, psychotic, heart failure, etc;

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Thyroid Small Group Cases for Students 2012