CASE PROTOCOL GRAVES DISEASE

GENERAL DATA This is a case of M.D., a 34-year old female, cabin stewardess, Roman Catholic, Filipino, single, from Batangas City, born on January 19, 1977 who was admitted at our institution last May 4, 2012.

CHIEF COMPLAINT: anterior neck mass

HISTORY OF PRESENT ILLNESS: (Poor history taking) Patient is a known case of hyperthyroidism secondary to Graves disease. Interval history revealed gradual enlargement of neck mass. Upon consultation, patient was advised surgery hence this admission.

PAST MEDICAL HISTORY: No hypertension, diabetes mellitus II, cardiovascular disease, renal disease

FAMILY HISTORY: (?)

PERSONAL AND SOCIAL HISTORY: (?)

REVIEW OF SYSTEMS: (?)

PHYSICAL EXAMINATION: Conscious, coherent, ambulatory, not in cardiorespiratory distress BP: 130/90 CR: 72 RR: 19 T: 36. 5

Pink palpebral conjunctivae, anicteric sclerae Supple neck, no neck vein engorgement, (+) neck mass 5 x 3 cm Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, normal rate, regular rhythm, no murmur Soft, NABS, no tenderness No gross deformities, full and equal pulses

ADMITTING DIAGNOSIS: Hyperthyroidism secondary to Graves disease, in euthyroid state

COURSE IN THE WARD: Upon admission, patient was immediately placed on NPO and venoclysed with PNSS 1L 25 gtts/min. Patient underwent subtotal thyroidectomy, right which revealed a thyroid gland measuring 5 x 2 cms. Pyramidal lobe was noted. Patient tolerated the procedure well. Patient was clinically stable and vital signs were normal. The following post-operative medications were given: Cefazolin (Stancef) 500mg/IV every 8 hours which was eventually shifted to Amoxicillin 500mg/cap TID for 1 week, Eterocoxib (Arcoxia) 90 mg/tab one tab TID for 3 days, Tranexamic acid (Hemostan) 500mg/tab one tab TID. Patient was then placed on diet as tolerated. Patient had an unremarkable stay at the ward. Patient had dry intact dressing, patent JP drain, good phonation, no signs of hypocalcemia (numbness, tingling, carpopedal spasm, Trousseaus sign) and afebrile. Patient was discharged stable and improved on the 2nd hospital day (Post-op Day 1).

FINAL DIAGNOSIS: Hyperthyroidism secondary to Graves disease, in euthyroid state

OPERATIVE PROCEDURE: Subtotal thyroidectomy, right

LABORATORIES CBC 05/02/12 Hgb HCT RBC Platelet WBC Segmenters Lymphocytes Monocytes Eosinophils Clotting time: 445 Bleeding time: 115 Prothrombin time 05/02/12 APTT Control Protime Percent activity INR control 37.8 38.0 11.1 100% 0.94 11.8 134 0.39 4.62 221 5.3 0.56 0.38 0.04 0.02 Ref. Range 120-160 0.37-0.54 4.0-5.4 150-400 5.0-10.0 0.55-0.70 0.25-0.40 0.02-0.08 0.01-0.06

Immunology 05/02/12 FT3 FT4 TSH 2.95 0.709 1.53 Reference range 3.1-6.8 0.93-1.7 0.27-4.2

Ultrasound of the thyroid 01/28/12 Both thyroid lobes are normal in size with heterogenous echo pattern. The right lobe measures 3.5 x 1.7 x 1.9 cm while the left lobe measures 4.5 x 1.4 x 1.8 cm. No focal mass seen. Isthmus measures 0.2 cm Impression: Normal sized thyroid gland with diffuse parenchymal changes.

HISTOPATHOLOGY 05/04/12 Patho No. 2012-1372 Diagnosis: Diffuse thyroid hyperplasia with involutional changes (left and right lobes)