Multinodular non-toxic goiter thyroid malignancy Medical Presentation

Thyroid Case PowerPoint Presentation

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Published on : Sep 26, 2017 | Views : 2420 | Downloads : 15

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lolliwels

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Good Day!! Raymond De Gula Clinical Clerk
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General Data C.E. 52/F Single
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Anterior Neck Mass 52/F Chief Complaint
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History of Present Illness 52/F
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52/F 9 months PTA Enlarging neck mass Palpitations Dizziness Difficulty of breathing Easy fatiguability Prompted consult AP NST (normal) Isthmus biopsy (benign features) UTZ enlarged thyroid lobe Left with solid nodules Prescribed Levothyroxine 100mg OD provided minimal relief of symptoms HISTORY OF PRESENT ILLNESS
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52/F 5 months PTA Neck mass persisted now with associated pain with the former symptoms RPT UTZ : minimal increase in size of neck mass. Hence consultation and subsequent admission HISTORY OF PRESENT ILLNESS
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52/F (+) HPN 4-5 years Losartan + Hydrochlorothiazide 150mg + 12.5mg/OD (-) Heart Disease (-) Asthma (-) Tuberculosis (-) Convulsion (-) Allergy (-) exposure to radiation (+) surgery Thyroid Lobectomy Right (1994) On Levothyroxine treatment Past Medical History
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52/F (+) HPN- BOTH (+) DM – BOTH (+) Heart Disease - BOTH (-) Bronchial Asthma (+) Cancer (lungs, breast, cervix, endometrial, colon) Paternal and maternal (+) Thyroid problem – mother, siblings Family History
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52/F (-) smoker (-) alcoholic beverage drinker Diet: fish, meat, vegetables Personal and Social History
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52/F PHYSICAL EXAMINATION
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52/F PHYSICAL EXAMINATION General Survey: Awake, conscious, coherent, not in cardiorespiratory distress Vital Signs: BP:120/80mmHg PR: 88 RR: 19 Temp: 36 Weight: 62kgs
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52/F PHYSICAL EXAMINATION Skin: brown, warm, moist, elastic, with good skin turgor HEAD: Normocephalic, no mass, no lesions EYES: pinkish palpebral conjuctiva, anicteric sclerae, pupils equally round and reactive to light and accommodation EAR: No aural discharge
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52/F PHYSICAL EXAMINATION Nose: Patent nasal passages, midline septum, frontal and maxillary sinuses non-tender Throat: No tonsillopharyngeal congestion; no cervical lymphadenopathy, midline trachea, (+)palpable ovoid mass – 6cm x 4cm on left anterior neck area, firm, movable, with palpable nodules, non tender, does move with deglutition Chest and Lungs: Symmetric chest expansion, no intercostal retractions, clear and equal breath sounds
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52/F PHYSICAL EXAMINATION Heart: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Flabby, non tender, normoactive bowel sounds on all quadrants, tympanitic on all quadrants
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52/F PHYSICAL EXAMINATION Genitourinary: Non-distended bladder Extremities: Full, equal pulses on both extremities, no edema Neurologic: No focal neurologic deficits Rectal Examination: Not assessed
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Multinodular non-toxic goiter R/O thyroid malignancy Admitting Impression: 52/F
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52/F Course in the Ward Diagnostic Workups
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52 / F X-RAY (CHEST PA or AP) 09/07/2017 Both lung fields are clear Heart is not enlarged Diaphragm and sinuses are intact
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52 / F ELECTROCARDIOGRAPHIC REPORT 9/07/2017 Normal Sinus rhythm
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52/ F
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52 / F
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9/04/2017
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Ultrasound of Thyroid Gland with Color Flow 7/26/2017 S/P Right Thyroidectomy Enlarged Multinodular Left Thyroid Lobe No significant change in sizes of mass/nodules (+) intranodular vascularity in the largest mass (With calcifications)
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DIFFERENTIAL DIAGNOSIS
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Papillary Thyroid Carcinoma Most common form Most patients are euthyroid Due to exposure to radiation Slow growing painless mass on the neck Women:men 2:1 FNAB: Orphan Annie Nuclei, Psammoma Bodies Invasive, possible metastasis
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Follicular Carcinoma Solitary thyroid nodules Differentiated from a thyroid follicular lesion because of capsular and vascular invasion No cervical lymphadenopathy
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Medullary Thyroid Carcinoma Originates in the parafollicular C cells which produces calcitonin Unilateral but is multicentric in familial types Tumors also secrete CEA Familial MTC has the worst prognosis
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Multinodular Non Toxic Goiter May be a result of iodine deficiency or TSH stimulation secondary to inadequate thyroid hormone synthesis Euthyroid state Goitrogens: cassava and cabbages Some are familial causes asymptomatic
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Admission
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Operation Done: Completion Thyroidectomy
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1st Hospital Day
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2nd Hospital Day
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DISCUSSION 52 / F
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EMBRYOLOGY Arises as an outpouching of the primitive foregut around the 3rd week AOG originating at the base of the tongue in the vicinity of the foramen cecum Endoderm cells – thyroid follicular cells Neuroectoderm cells of paired lateral anlages – parafollicular C cells
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ANATOMY About 20g Posterior to the strap muscles Connected in the midline by isthmus Blood supply – superior thyroid arteries and inferior thyroid arteries Venous Drainage – superior, middle and inferior thyroid veins
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The thyroid gland is endowed with an extensive network of lymphatics: Pretracheal Paratracheal Perithyroidal Superior mediastinal Retropharyngeal Esophageal Upper, middle and lower jugular chain nodes
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Thyroid Physiology Iodine converted to iodide Thyroid hormone synthesis entails the following: Iodide trapping via NIS symporter Oxidation of iodide to iodine and iodination of tyrosine residues on Thyroglobulin Coupling of DIT and MIT molecules forming T3 and T4 Hydrolysis of Tg to release free iodothyronines Deiodination of MIT and DIT to be reused 52/ F
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52/ F FINAL DIAGNOSIS: MULTINODULAR NON TOXIC GOITER S/P Completion Thyroidectomy
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Signs and Symptoms Neck mass Dysphagia and dyspnea (+) Pemberton Sign Acute pain Nodules of various sizes and consistency upon palpation May have tracheal Deviation with or without compression
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52/ F DIAGNOSTICS Thyroid Function test FNAB for dominant enlarging or painful nodule
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MANAGEMENT: If asymptomatic: none Surgical resection is indicated for: Continued increase despite T4 suppression Causing obstructive symptoms Substernal extension Suspected to be malignant Cosmetically unacceptable Treatment of choice: Total lobectomy on the side of dominant nodule and subtotal resection on the contralateral side Requires lifelong T4 therapy to prevent recurrence
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THANK YOU !