Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Goiter 가 오랜기간 제대로 관리되지 않으면 ? 내분비대사내과 R1 이지영 / 이상열교수님 │1│ MGR

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y 67/F 박 O 순 Chief complaint) 호흡곤란 Onset) 한달전 Present illness) 67 세 여자, 울혈성심부전 및 심방세동으로 심장내과, 류마티스 관 절염으로 류마티스내과, multinodular goiter 로 내분비내과 외래 추 적관찰 하는 자로, 약 한 달 전부터 시작된 기침과 더불어 운동시 호흡곤란 발생하여, 울혈성 심부전급성 악화로 본원 심 장내과 입원하였고, 경도의 호흡곤란 증상 지속되어 intrathoracic goiter 에 의한 airway narrowing 가능성 하에 goiter 에 대한 치료 위 해 내분비 내과로 전과됨. │2│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y │3│ Premedical history) DM/HTN/Hepatitis/Tuberculosis (-/+/-/-) Osteoporosis, diagnosed in 2014 Rheumatoid arthritis, diagnosed in 2013 Atrial fibrillation, diagnosed in 2012 Goiter, diagnosed in Medication- Furosemide 40mg bid Methotrexate 12.5mg/week Spironolactone 25mg bid Hydroxychloroquine 200mg qd Warfarin 1mg qd Prednisolone 7.5mg qd Bisoprolol 1.25mg qd Folic acid 1mg qd Acetaminophen 300mg bid Alendronate 70mg/week Pre-surgical history) Arthrodesis interphalangeal joint, Rt. d/t OA thumb, Rt. (2008) TKR,Lt. d/t OA knee, Lt. (2010) Family history) unremarkable Personal history) alcohol (-) smoking (-)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Review of System  Generalgeneral weakness (+) fever (-) chills (-) weight change (-)  Skinrash (-) pruritus (-)  HEENTneck swelling (+) swallowing difficulty (-)  Chestcough (+) sputum (-) dyspnea (+) palpitation (-) :NYHA class IV  Abdomenanorexia (-) nausea (-) vomiting (-) abdominal pain (-)  Urogenitaldysuria (-) hematuria (-) frequency (-)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Vital sign: 150/90 mmHg – 88/min – 20/min – 36.1°C Height : 148cm Weight : 62kg BMI : 28.3 kg/m 2 Physical Examination  General appearancealert & oriented  HEENT palpable thyroid enlargement (+) : well-defined, diffuse enlargement bruit (-) tenderness (-) LN enlargement (-)  Chest coarse breathing sound with rale irregular heart beat without murmur  AbdomenSoft & nontender abdomen  Motor, sensory V V

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y CBC/DC 7,930/uL – 8.8 g/dL – 28.6% – 339,000/uL (Seg. neutrophil 90.3%) (MCV 81.6 fL MCH 25.1 pg MCHC 30.8 g/dL) PT INR 1.30 aPTT 31.8 sec Chemistry TB 0.58 mg/dL Pro/Alb 5.7/3.6 g/dL AST/ALT24/26 U/LALP/GGT 92/148 U/L Glucose106 mg/dLBUN/Cr 20/0.6 mg/dL Na/K/Cl141/3.6/111 mmol/LCa/P/Mg 8.3/2.4/1.7 mg/dL LD 455 U/L Uric acid 6.1 mg/dL T-Chol112 mg/dL CK/CK-MB/Troponin-I 40/1.1/0.01 U/A RBC 0~1/HPF WBC 2~4/HPF Laboratory Finding ( ) │6│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y TFT from 1995 to present TSH (uU/mL) Free T4 (ng/dL) T3 (ng/dL) │7│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Chest X-ray ( ) │8│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y ECG ( ) │9│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Chest CT (2014.4) │10│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Chest CT (2014.4)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Ultrasound (2003)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Ultrasound (2012)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Fine needle aspiration (2012) Thyroid (right, left, and isthmus) : consistent with a benign follicular nodule (includes adenomatoid nodule, colloid nodules)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Ultrasound (2014.3)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Scintigraphy (Tc-99m pertechnetate 10mCi) (I-131 scintigraphy) Uptake (20min) : 2.8% Uptake (2hr) : 6.3% Uptake (24hr) : 14.2%

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Bone mineral density (2014.2)

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y #1. Toxic multinodular goiter / Intrathoracic goiter #2. Congestive heart failure a/w A.fib #3. Rheumatoid arthritis #4. Osteoporosis #5. Anemia #6. HTN Impression │18│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Plan #1. Toxic multinodular goiter/Intrathoracic goiter Thyroid scan to measure the weight of thyroid Surgery or radioactive iodine thearpy TFT f/u

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y 환자 수술적 치료에 거부감 있으며, 전신 상태 및 수술 후 발생할수 있는 합병증 가능성 고려하여 외래에서 방사성 동위원소 치료하 기로 하고 퇴원함.

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Scintigraphy (Tc-99m pertechnetate 10mCi) Right lobe : gram Left lobe : gram Right lobe : gram Left lobe : gram

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Radioactive iodine therapy I mCi ( )

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y TFT from 1995 to present TSH (uU/mL) Free T4 (ng/dL) T3 (ng/dL) │23│

Towards Global Eminence K Y U N G H E E U N I V E R S I T Y #1. Toxic multinodular goiter / Intrathoracic goiter s/p RAI #2. Congestive heart failure a/w A.fib #3. Rheumatoid arthritis #4. Osteoporosis #5. Anemia Final diagnosis │24│