1. Endocrinology Case Buyucan, K. Cueto, M. Cunanan, S. Dadgardoust, P. Daguman, E. Dator, D.

2. General Data FP Female 53 year old Tondo, Manila

3. Chief Complaint Hoarseness of voice

4. History of Present Illness 15 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.

5. 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

6. Past Medical History Previous Hospitalizations: none Major childhood illnesses: none Major adult illness: minimal PTB, hypertension Immunizations: unrecalled

7. Past Medical History Medication: Therabloc 25 mg 1 tab every morning Meloxicam 15 mg 1 tab once a day Caltrate Plus once a day Paracetamol 1 tab q 8 hours PRN for mild to moderate pain Sulidin gel apply to affected area PRN for pain Adverse drug reactions:none

8. 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

9. Family History (+) cancer(sibling) (-) PTB (-) diabetes (-) hypertension (-) stroke (-) allergies (-) asthma (-) heart disease

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

11. Review of Systems General: (-) weight loss(-) loss of consciousness Specific organ/ SystemSymptom 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 Necksee HPI Breast(-) palpable breast masses, (-) nipple discharge, (-) tenderness, (-) breast enlargement Cardiovascular(+) palpitations, (-) chest pains, (-) PND, (-) orthopnea

12. Review of Systems Specific organ/ SystemSymptom 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

13. Physical Exam General Survey: conscious, coherent, ambulatory Vital signs: BP: 110/60mmHg PR 120bpm, regular RR 30cpm T 39.0 0 C Ht: 152 cm, Wt: 52 kgs

14. Physical Exam Skin Warm, dry skin, no active dermatoses, (-) alopecia (-) rashes (-) spider angiomata Head 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

15. Physical Exam Neck 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 nodes Respiratory Symmetrical chest expansion, no intercostal retractions unimpaired tactile and vocal fremiti on both lung fields resonant on percussion clear breath sounds, no wheezes, crackles

16. Physical Exam Cardiovascular Adynamic precordium, AB 4 th LICS MCL, (-) heaves, thrills and lift, S1>S2 at the apex, S2>S1 at the base, (-) murmurs Abdomen 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

17. Physical Exam Extremities Pulses full and equal on all extremities

18. PATHOPHYSIOLOGY

19. 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)

20. 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

21. 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

22. 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)

23. Laboratory Tests and Work-ups (Pre-Op)

24. Thyroid Function Test AnalyteResultsReference Value FT32.561.45-3.48 pg/ml FT41.170.71-1.85 ng/dl TSH0.2600.47-4.64 UIU/ml

25. 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

26. 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

27. (Post-Op)

28. Thyroid Hormone Thyroxine should be administered to ensure that the px remains euthyroid TSH suppression

29. 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

30. Management and Treatment

31. 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

32. 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