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.

Presentation on theme: "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."— Presentation transcript:

1 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

2 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 11138639 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 2014.4.17 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│

3 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 1995 -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 (-)

4 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 (-)

5 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, sensory100 100V V

6 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 (2014.4.17) │6│

7 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 1995200420052007200820092010201220132014.3 TSH (uU/mL) 0.160.060.150.180.130.090.070.350.02 Free T4 (ng/dL) 2.161.561.661.541.522.261.722.211.75 T3 (ng/dL) 17714214912396112 │7│

8 Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Chest X-ray (2014.4.17) │8│

9 Towards Global Eminence K Y U N G H E E U N I V E R S I T Y ECG (2014.4.17) │9│

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) │10│

11 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)

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

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

14 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)

15 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)

16 Towards Global Eminence K Y U N G H E E U N I V E R S I T Y Thyroid Scintigraphy 2014.3 (Tc-99m pertechnetate 10mCi) 2003.9 (I-131 scintigraphy) Uptake (20min) : 2.8% Uptake (2hr) : 6.3% Uptake (24hr) : 14.2%

17 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)

18 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│

19 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

20 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 2014.5.2 퇴원함.

21 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 : 107.7 gram Left lobe : 138.3 gram Right lobe : 107.7 gram Left lobe : 138.3 gram 2014.5

22 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-131 20 mCi (2014.5.9)

23 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 1995200420052007200820092010201220132014.32014.5 TSH (uU/mL) 0.160.060.150.180.130.090.070.350.02 0.1 Free T4 (ng/dL) 2.161.561.661.541.522.261.722.211.752.26 T3 (ng/dL) 17714214912396112116 │23│

24 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│