ENDOCRINOLOGY FILES

ENDO_2

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS:  Large colloid goiter.

FINAL DIAGNOSIS:  Large colloid goiter.

PROCEDURE:  Total thyroidectomy.

COMPLICATIONS:  Bibasilar discoid atelectasis with probable pneumonitis.

HISTORY:  This is a 68-year-old woman who was seen probably about 3 years ago with a large colloid goiter. She was going to have surgery then but declined and came back in more recently because of increasing size of the goiter and the pressure symptoms in her neck and throat. Studies previously done showed this to be a nontoxic goiter. She was essentially euthyroid. Because of its increasing size, the possibility of malignancy had to be considered.

Physical examination was not remarkable except the patient being somewhat overweight and the large goiter which was visible and the right side being larger than the left. The patient, because of religious customs, would not allow a pelvic or rectal examination.

Following surgery, the patient had no problem speaking. She is swallowing and eating solid food. Throat is sore. She did develop a temperature upto 101 and had some rhonchi in both bases on auscultation. Chest x-ray shows discoid atelectasis with probable pneumonitis. Her white count was elevated at a little over 12,000 with a left shift. Temperature this morning is 100 degrees.  The wound is clean and dry. The drain has been removed, and one-half of the staples are removed. She will be continued on tetracycline 500 mg q.i.d., and she is instructed to take her Lanoxin daily and her Dyazide as well. We are giving her Synthroid, and she is to take that every day. I have stressed the importance to her son of taking the Synthroid, as she should have no thyroid function. Her calcium was 8.6.

ENDO_3

CHART NOTE

A 26-year-old referred for Graves disease.  Patient first found to be hyperthyroid shortly after she became pregnant, was placed on PTU 350 g taken in divided doses until 1 week prior to delivery.  She has all the classical symptoms of hyperthyroidism, including tremor, soft frequent stool, being hot, insomnia, weakness in her legs, and exophthalmos.

On physical examination, extraocular movements were fairly full except that she could not converge.  Examination of her thyroid revealed the gland to be at least 2 times the normal size with classical, rather mushy, soft feeling of hyperthyroidism.  No nodules were noted.  Examination of her skin revealed normal amounts of forearm hair but extension of hair on the backs of her hands.  She was also beginning to get hair formed on the upper lip at the corners of her mouth.  There is no periareolar hair; however, she has a well-developed male escutcheon.

I talked with the patient about this, and when she has been euthyroid for a bit, we will consider measuring her androgen level.  Patient was asked to discontinue PTU and to obtain a T4 and T3.  Appointment was made with Nuclear Medicine for her to have an uptake scan and therapy next week.  I decided to investigate the androgen problem at a later date when we will not have the effect of thyroxine on liver metabolism.

ENDO_4

CHART NOTE

One grain of thyroid did not work as well as 1-1/2 in terms of reducing facial and neck edema.  When she sleeps away from home; however, the edema does not occur.  It is almost certainly an allergy to some component of her house.  I suggested, since she is going to college, that she try to taper and discontinue the thyroid over a 3-month period.  Will return in 6 months if still on 1-1/2 grains, otherwise 1 year if on a lower dose of thyroid.  Pulse 75, blood pressure normal.  Heart and lungs okay.  Has a small mole which does not appear to be a problem.

ACTH injection given for adrenal tests.

ENDO_5

DISCHARGE SUMMARY

This was one of several admissions for this nearly 3-year-old boy for bilateral inguinal hernia repairs.  Swelling in the left groin was noted several weeks prior to admission.  He has had pains in the groins on and off.  He was found to have bilateral inguinal hernia repairs.  The child is also followed because of congenital Addison disease.  He is on Cortef and Florinef Acetate.

Because of the Addison disease, he was treated with cortisone acetate IM, 50 mg on admission, and Solu-Cortef 50 mg IM 1 hour prior to surgery.  Solu-Cortef 50 mg was run during the surgery.  Four hours after completion of the surgery, he received 12.5 mg of Solu-Cortef IM.

LABORATORY DATA:  Hemoglobin 12.1.  WBC 5500.  BUN 18 and electrolytes 140, 3.9, and 23.

DISCHARGE DIAGNOSES

1.  Addison disease.

2.  Bilateral inguinal hernias.

Discharge medication included only his usual medications for Addison disease.

ENDO_6

CHART NOTE

A 34-year-old lady who comes to clinic today with a long-standing history of hypothyroidism, for which she has taken Cytomel in the past.  Comes in today for a refill of medication and further evaluation.

Examination shows her to be in no acute distress.  Blood pressure 120/88.  HEENT normal.  Chest is clear.  Cardiac examination reveals regular rate and rhythm without murmur.

ASSESSMENT:  A 34-year-old lady with long-standing hypothyroidism.  I would prefer to switch her to Synthroid 0.1 mg, as I think the packaging is more uniform in this product.  Then test TSH (thyroid stimulating hormone) in 1 month.

ENDO_7

CHART NOTE

The patient is a 71-year-old female who was noted to have a slowly enlarging lesion in the right lobe of her thyroid.  Scans revealed this to be a cold nodule.  Thyroid function studies were within normal limits.  Fine-needle aspiration of this was thought to be a Hurthle cell adenoma.

The patient’s physical examination revealed a 2 x 1 x 1 mass in the right upper pole of the thyroid.  There were no lymph nodes palpable.  Patient was moderately obese but otherwise was unremarkable.

The patient did have an exploration of her right neck, and this was found to reveal a smooth mass in the right lobe of the thyroid lobectomy was performed.  The left lobe was totally unremarkable and was not resected.

FINAL DIAGNOSIS:  Follicular adenoma of the right lobe of thyroid with Hurthle cell change.