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 ultrasound imaging 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 neck pain or difficulty swallowing. He has no history of external irradiation of his head or neck and no family 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 of cervical lymphadenopathy. Pembertons sign is absent. Laboratory Test: Thyroid Ultrasound Report: TSH 2.53 mU/L (normal range 0.5 to 5.5 mU/L) 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 in the lower pole of the right thyroid lobe. It has some intrinsic vascularity. Two nodules are seen in the upper pole measuring 0.6 x 0.7 x 0.5 cm and 0.7 x 0.8 x 0.6 cm. In the left thyroid lobe a hypoechoic nodule is present which measures 0.4 x 0.5 x 0.4 cm. Recommend thyroid scintigraphy for further evaluation of the thyroid lesions.

The patient is not overly concerned about the mass but wants to know whether he really needs to undergo additional studies or tests? Questions: 1. What is your suspicion with respect to the nodule based on the clinical and biochemical information 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 among sexes? 5. What would be the treatment in case the thyroid nodule was found to be a papillary thyroid carcinoma? Beta rays

EndoRepro 2012 Small Group Cases - Thyroid

Case Discussion 2 A 27-year-old woman, who has been generally healthy and very active all of her life, presents with 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 in finishing her doctoral thesis on The Impact of Energy Conservation on the Environment. While she did not have a problem climbing a tree about two years ago, she has now some difficulties walking up the stairs. Her menstrual periods have recently become irregular but a pregnancy test was negative. Her older sister, who was diagnosed with a low thyroid and is taking some thyroid medication, told her to see a doctor. She is somewhat depressed and comes to find out whats 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 her hands and skin are cool. You palpate an enlarged and firm thyroid with a slightly irregular surface and you find sluggish deep tendon reflexes with a delayed (hung up) relaxation phase. Questions: 1. 2. 3. 4. 5. 6. Given this young womans clinical signs and symptoms, what is the most likely diagnosis? What is the most likely cause of this patients condition based on her history and physical findings? What is the most sensitive laboratory test to confirm her diagnosis? What additional laboratory tests are helpful? What results do you expect and why? How will you treat this patient? Assuming that you treated her condition well and she becomes pregnant several months later, would you have to make any adjustments to her treatment? Explain. Enumerate the possible consequences if her condition was left untreated and she continued to deteriorate. How is this called?

EndoRepro 2012 Small Group Cases - Thyroid

Case Discussion 3 A 43-year-old woman is complaining of nervousness and insomnia. She feels easily flying of the 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 her bowels about twice a day. However, she experiences frequent palpitations and feels always hot. These symptoms started several months ago and were accompanied by grittiness in her eyes. Her eye problems have worsened over time and she now has the feeling as if her eyes are being pushed out of her head. She recently overheard a co-worker calling her the PopEye. She has begun to notice occasional double vision. She smokes about a pack a day for the last 15 years. On examination, the patient appears restless. Her blood pressure is 135/60 mm Hg, her resting heart rate is 98 beats per minute and her temperature is 99.1 F. She has lid lag, bilateral proptosis and a restricted upward gaze of her left eye. Her thyroid is symmetrically enlarged and, 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 and she 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 which pathologic mechanisms are involved in its disease-specific development? How can you treat her hyperthyroidism? Untreated hyperthyroidism can decompensate into a life-threatening emergency during an intercurrent illness or a surgical emergency. How do such patients present and what do you call this condition? 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 the normal range? Does this condition increase the risk of other medical problems?

2. 3.

4.

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