Case study Group 2 presentation

Transcription

1 Case study Group 2 presentation

2 Patient profile HN Female 60 years old Hometown : Sa Kaeo province Occupation : farmer No drug and food allergy

3 Chief complain Left neck mass 10 years PTA that gradually growth.

4 Present illness Left neck mass Chronic bone pain U/D : HT, Gout

5 Physical Examination BP 120/80, Body temp 37.5⁰C, RR 22, PR 88 Left neck mass 4 cm. smooth surface, soft consistency move by swallowing.

6 Problem list Left neck mass 4 cm. smooth surface, soft consistency move by swallowing. Chronic bone pain.

7 Differential Diagnosis Thyroid mass Parathyroid mass Lymphadenopathy

8 Provisional Diagnosis Thyroid cancer with bone metastasis

9 Lab investigation Hb 9 g/dl (12-16) Hct 24.8 % (36-47) Red Cell Count 3.79 x 10^6 / mm3 ( ) MCV 65.4 fl (80-95) MCHC 36.3 g/dl (32-36) RDW 16 % (12-14) White Cell Count x 10^3/mm3 (4-10)

10 Lab investigation BUN 8.4 mg/dl (6-20) Cr (enzymatic) 1.21 H mg/dl ( ) egfr (MDRD) ml/min ( >90 ) egfr (CKD-EPI) ml/min ( >90 ) PTH 129 H pg/ml (15-65)

11 Lab investigation Mg 0.5 mg/dl ( ) P 3.92 mg/dl ( ) Na 108 mmol/l ( ) K 5.87 mmol/l ( ) Cl 73 mmol/l (98-107) HCO mmol/l (22-29) Anion gap (8-20)

12 Lab investigation Color : yellow Specific gravity : ( ) ph : 6.5 (5-7) Glucose : Negative Protein : trace (<30 mg/l) Erythrocyte : 4+ WBC : 5-10/HPF Urobilinogen, Bilirubin : Negative

13 Lab investigation ICD9 needle aspiration of thyroid gland. ICD10 disorder of thyroid. FNA : benign follicular nodule U/S thyroid U/S kidney CT : Whole abdomen, Head and Neck, Chest Plain film : Hand, Skull, Hip, Spine, Chest, Abdomen

14 Approach Film A large well defined heterogeneous hypoechoic mass site 4.6 x 2.4 x 2.4 cm. at posterior left lobe thyroid.

15 Approach Film Geographic osteolytic lesion at right humerus and clavicle and mass in anterior rib

16 Approach Film Diffuse osteolytic lesion that has resulted in Salt and pepper appearance

17 Approach Film Lytic lesions at right middle phalanx of index finger cortical resorption of the middle phalanges terminal tuft resorption at distal phalanx of both hand

18 Approach Film Geographic osteolytic lesion at both femur

19 Approach Film

20 Approach Film Diffuse osteoporosis, increase radiolucent spine and biconcave of vertebral body : Fish vertebrae

21 Approach Film

22 Approach Film Osteolytic lesions with ballooning medullary canal of anterior aspect of hard palate

23 Radiopaque lesion at both kidney Approach Film

24 Approach Film Medullary nephrocalcinosis of both kidneys and hyperechoic lesion with posterior acoustic shadow

25 Approach Film Tiny stone at left distal ureter

26 Tiny stone at left UVJ Approach Film

27 Conclusion Thai female 60 years old present with left neck mass 4 cm. smooth surface, soft consistency move by swallowing U/S thyroid : well defined heterogeneous hypoechoic mass at posterior left thyroid U/S kidney : hyperechoic lesion with posterior acoustic shadow at both kidney CT chest : mass in right anterior rib

28 Conclusion CT head and neck : mass at posterior left thyroid and osteolytic lesion at anterior aspect of hard palate CT whole abdomen : medullary nephrocalcinosis of both kidney and two tiny stone at left distal ureter and left UVJ Plain film : salt and pepper skull, osteitis fibrosa cystica, osteoporosis (increased radiolucent on vertebral body)

29 Conclusion Final diagnosis : hyperparathyroidism due to parathyroid adenoma

30 Treatment Parathyroidectomy Calciferol (Vitamin D2) Calcium carbonate Ferrous fumarate Alfacalcidol (analog Vitamin D) Folic acid

31 Knowledge : hyperparathyroidism

32 Hyperparathyroidism Primary Hyperparathyroidism Secondary Hyperparathyroidism Tertiary Hyperparathyroidism

33 Primary Hyperparathyroidism one or more of your parathyroid glands become enlarged and overactive. Due to Parathyroid adenoma : most common cause Parathyroid hyperplasia : usually affects more than one gland at the same time Parathyroid carcinoma : Very rarely

34 Primary Hyperparathyroidism Clinical presentation - asymptom - symptom - muskuloskeletal cortical bone loss bone & joint pain osteitis fibrosa cystica salt & pepper skull

35 Primary Hyperparathyroidism Clinical present - renal kidney stone, nephrocalcinosis - GI anorexia, nausea & vomiting conspitation

36 Primary Hyperparathyroidism Clinical present - neuromuskular & psychologic proximal myopathy, weakness - cardiovascular hypertension bradycardia

37 Primary Hyperparathyroidism LAB Parathyroid hormone level Ionized serum calcium level

38 Secondary Hyperparathyroidism Include: is the result of another condition that lower calcium levels. Severe calcium deficiency : Not get enough calcium from your diet, often because digestive system. Severe vitamin D deficiency. Chronic renal failure : most common cause

39 Secondary Hyperparathyroidism Clinical present - renal failure - bone disease osteitis fibrosa cystica rugger-jersey spine - vitamin D deficiency - osteomalacia - increase fracture risk

40 Secondary Hyperparathyroidism LAB - Parathyroid hormone - Low normal serum Calcium - Phosphate level - High : renal insufficiency - Low : vitamin D deficiency

41 Tertiary Hyperparathyroidism After long standing secondary hyperparathyroidism and resulting in hypercalcemia Clinical presentation Lab - Hypercalcemia in the setting of chronic secondary hyperparathyroidism - Normal or elevated of parathyroid hormone - Phosphate level is often elevated

42 Take home message Radiological investigations for primary hyperparathyroidism Musculoskeletal : salt and pepper skull, osteitis fibrosa cystica, osteoporosis, Fish vertebrae appearance Renal : Nephrocalcinosis, renal stone