NYU Medicine Grand Rounds Clinical Vignette Jenny Ukena, PGY2 9/18/2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

30 year old woman with neck enlargement for 1 year Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

One year prior to presentation, the patient reports that her neck was increasing in size She also noted that her neck was occasionally painful and/or pruritic during this time The patient then presented for a routine Gynecology appointment where she was noted to have an enlarged thyroid on physical exam and was sent to Endocrinology clinic for further evaluation History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: Gastroesophageal reflux disease Past Surgical History: Two Cesarean sections Social History: No smoking, alcohol, or drug use Patient originally from Mexico, has two children Family History: No family history of thyroid disease or thyroid cancer Allergies: No Known Drug Allergies Medications: Ranitidine 150 mg by mouth twice daily, Norgestimate/ethinyl estradiol 1 tablet by mouth daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: Well appearing woman in no acute distress Vital Signs: T: 98.6 F BP: 126/79 HR: 88 RR: 17 and O2 sat: 100% on room air Thyroid irregular, 2 cm right sided nodule Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings Thyroid stimulating hormone: CBC and basic metabolic panel were within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies Chest X-Ray: no cardiopulmonary disease Thyroid Ultrasound: Right lobe: 5.8 x 2.0 x 1.8 cm, 2.6 x 2.3 x 3.7 solid hypoechoic, hypovascular nodule in the inferior aspect extending to the right side of the isthmus with numerous calcifications Left Lobe: 4.4 x 1.3 x 1.7 cm, 1.3 x 0.9 x 1.4 cm slightly hypoechoic solid nodule in inferior aspect with multiple calcifications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

The working diagnosis at this time was papillary thyroid carcinoma Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Outpatient workup: –Laboratory values: thyroglobulin antibody negative, thyroperoxidase antibody 18.9 (negative), thyroxine level free serum 1.02 –Fine needle aspiration: the right nodule was positive for malignancy (Bethesda Class VI) papillary thyroid carcinoma and the left nodule was suspicious for malignancy (Bethesda Class V) suspicious for papillary carcinoma Outpatient Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Course C Hospital Day 1: –The patient underwent total thyroidectomy without complication –Pathology showed papillary thyroid cancer, classic type, well differentiated, partially encapsulated, with focal lymphovascular invasion –Three foci of papillary microcarcinoma, follicular variant present –Lymph node resection: metastatic papillary thyroid carcinoma involving one lymph node U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Course Hospital Day 2: –Patient was discharged on levothyroxine 112 mcg by mouth once daily and calcium supplement –The plan was for outpatient follow up and Radioiodine treatment

The final diagnosis was papillary thyroid carcinoma Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS