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NYU Medical Grand Rounds Clinical Vignette. Arnab Ghosh, MD PGY-2 10/23/12. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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Nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Arnab Ghosh, MD

PGY-2

10/23/12

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS


Chief complaint

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

The patient is a 67 year old male who presented to his primary care physician with palpitations.


History of present illness

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • When reviewed in clinic by his primary physician, he appeared clinically euthyroid although he did have evidence of an enlarged thyroid gland on examination by his primary care physician.

  • He was referred to an endocrinologist.


Additional history

Additional History

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Past Medical History: Nil

  • Past Surgical History: Nil

  • Social History: Works as a dentist, occasional social drinker, non smoker, nil illicit drug use

  • Family History: Nil family history of thyroid disease

  • Medications: Nil


Physical examination

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • General: He appeared well

  • Thyroid Examination: a palpable thyroid approximately one and a half times the normal size

    • Nil evidence of tenderness, dominant nodules nor lymphadenopathy

    • Nil peripheral stigmata of thyroid disease

  • Remainder of Physical Exam was normal


Laboratory findings

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • CBC: within normal limits

  • Basic Metabolic panel: within normal limits

  • Hepatic panel: within normal limits

  • Thyroid Stimulating Hormone (TSH)

    • 2.7 miU/L (N:0.4-4.0 mIU/L)

  • T4 5.9 mcg/dL (N: 4.8-11.0 mcg/dL)

  • T3 0.78 ng/mL (N:0.8-1.7 ng/mL)

  • Anti-thyroglobulin antibody: 2.4 U/mL (>1.0 U/mL – positive)

  • Anti-thyroperoxidase antibody:14.0 U/mL (>1 U/mL – positive)


  • Other studies

    Other Studies

    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    • ECG: normal sinus rhythm with occasional premature ventricular contractions

    • Thyroid Ultrasound:

      • 1.7x1.1cm nodule in the R lobe (hypoechoic)

      • 9x11mm nodule in R lobe (hypoechoic)

      • Nil microcalcifications, nil increased vascularity

    • Fine Needle Aspiration performed of larger nodule:

      • Colloid in a population of lymphocytes


    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    Working Diagnosis

    Euthyroid lymphocytic thyroiditis


    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    Outpatient Course

    • The patient was referred back to his primary care physician, who intermittently checked TSH levels, which remained normal

    • 8 years later, the patient was referred back to his endocrinologist with a TSH measured at 4.16 mIU/L (N:0.4-4.0mIU/L)

    • Patient was clinically euthyroid during this time


    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    Outpatient Course

    • On repeat labs by the endocrinologist, the TSH was measured 11.4 mIU/L

    • Other laboratory values of note:

      • T4 6.3 mcg/dL (N: 4.8 - 11.0 mcg/dL)

      • T3 Uptake 31.7% (N: 23.5 - 40.6%)

      • Free thyroid index 4.0 (N: 1.5 - 3.8)

      • Anti-thyroperoxidase antibody: 239 IU/mL (normal < 27 iU/mL)

      • Anti-Thyroglobulin antibody: < 20 IU/mL (normal)


    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    Outpatient Course

    • Repeat Thyroid Ultrasound performed:

      Coarsely and diffusely multinodular

      Mild hyperaemia of the entire thyroid

      R lobe: 2 solid hypoechoic nodules, 15x10mm and 9x9mm

      L inferior lobe: 8x6mm nodule

      Nil calcifications

      • Fine Needle Aspiration of 3 nodules:

        R and L nodules: colloid with lymphocyte background

        L inferior lower lobe: colloid accumulation


    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    Outpatient Course

    The patient was started on Levothyroxine 25 μmcg daily by mouth


    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    Outpatient Course

    Repeat lab values 3 months later in clinic

    • TSH 2.74 miU/L (N:0.4-4.0 mIU/L)

    • T4 5.7 mcg/dL (N: 4.8 - 11.0 mcg/dL)

    • T3 Uptake 33.9% (N: 23.5 - 40.6%)

    • Free thyroid index 1.9 (N: 1.5 - 3.8)


    UNITED STATES

    DEPARTMENT OF VETERANS AFFAIRS

    Final Diagnosis

    Hashimoto’s thyroiditis (with failing thyroid)


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