Informant: Self

CC: “My voice sounds different” x a few weeks (Hoarseness)

Diagnosis: Papillary Thyroid Cancer

HPI:

38 years old reliable female with no significant PMHx came to the clinic complaining of hoarseness for the past few weeks. The pt states that the hoarseness began 6 weeks and it is progressively becoming worse. Pt describes the voice as raspy and rough as it sounds strange to her ears. The pt states, she has tried to alleviate the voice changes by drinking tea and warm water with no relief. Along with the hoarseness, pt complains of pain with swallowing solid foods. The pain with swallowing began before the voice change but pt is more concerned regarding her voice change as the swelling pain only occurs with solid foods. The pain is non-radiating and nothing makes the pain better. Pt rates the pain 8/10 at its worse and 4/10 at its best. Pt admits to having mild SOB and fatigue after a long day of work. Pt denies any weight loss or gain, chest pain, excessive sweating, tremor, N/V/D, constipation, irritability, bone pain, anxiety, depression, or any other symptoms.

 

PMHx: none

Surgical Hx– appendectomy at age 26 with no complication

Family Hx: – Mother has Hypothyroidism and father has HTN

Social Hx – denies smoking, drinking or illicit drug use

Fiona is a 38 years old white female who works as a radiologist assistance in the QHC hospital

 

Allergies: PCN  rash

Medications: Birth control pills and multi-vitamin pills

 

ROS:

HEENT: Denies ear pain, hearing changes, facial pain, c/o dysphagia for solids foods

Neck: denies stiffness or swelling/swollen glands

CVS: denies chest pain, palpitations, ankle swelling, PND, Orthopnea

Pulmonary: mild SOB denies cough

GI: denies N/V/D, constipation, abdominal pain, changes in Bowel Movement, bloating, anorexia, blood in stools, hemorrhoids

GU: Denies incontinence, dysuria, nocturia, urgency, flank pain, hematuria, urethral discharge

MSK:  denies joint pain

Neurologic: Denies memory issues, HA, dizziness, slurring speech, paresthesia, paresis, tremors

Psychiatric: Denies depression, anhedonia, nightmares, suicidal or homicidal ideation.

Endocrine: Denies cold/heat intolerance, polyphagia, polydipsia

Heme: fatigue after long day of work. Denies fever, jaundice, generalized weakness, easy bruising or bleeding

 

Initial Differential Diagnosis:  

• Benign thyroid nodule
• Thyroid cancer
• Subacute thyroiditis
• Goiter
• Hypothyroidism
• Advance reflex
• Benign Lesion

 

PE:

 VS:

BP 120/ 70 mm Hg seated, right arm

T 98.2, oral

HR 86bpm regular

RR 16 unlabored

SpO2 100% on RA

Ht 67”, Wt 135 lbs, BMI 21.1 – hasn’t changed in 6 months

 

Gen: Well-developed female. Alert and oriented x 3, Not in any apparent Distress, Compliant to exam. Dressed and groomed appropriately.

Skin: Warm and dry, good turgor

Head: Normocephalic and atraumatic

Eyes: clear sclera and conjunctivae, PERRLA, EOMs full without nystagmus

Ears: hearing intact to whisper test, clear canals.  Slight cerumen present in both canals, but TMs visualized and without lesions.

Mouth/Throat: Oral mucosa moist and pink. Mild periodontal disease noted. Tonsils are normal in size, free of exudates. Oropharynx normal.  Tongue midline.  Uvula rises symmetrically, tongue protrudes in midline

Neck: supple, no JVD. Carotids 2+ without bruits but a 2-cm firm, nontender nodule

in the right lobe of the thyroid gland was palpable, no movement with swallowing

lymphadenopathy was not evident

Heart: RRR, Normal S1 and S2, no Murmur/Rubs/Galaps noted

Lung: Clear to auscultation, no accessory muscle use

Abd: soft, non-tender.  No masses, lesions, or pulsations noted.  No organomegaly.  Liver edge firm. No guarding or rebound tenderness

GU: No inguinal adenopathy, no suprapubic tenderness.  Genital and rectal exam deferred

MSK: Grossly normal with good ROM all 4 extremities.  No joint swelling or deformity

CN: a V1-V3 intact, no facial asymmetry, equal elevation of palate

Motor: normal bulk and tone.  Strength symmetric. No tremors.  No pronator drift

Sensory: to pinprick intact all 4 distal extremities

DTR’s: 2+ throughout.  No clonus. Toes down-going, Gait normal

Extremities: No edema, clubbing, cyanosis

 

Labs: CBC, CMP, TSH, T4, Thyroglobulin Level, calcitonin

 

CBC and CBP with in normal limit

TSH- 1.8 [normal]

T4- 6.2 [normal]

Free T3- 300 pg/ml

Free T4- 1.0 ng/dL

ALL the lab tests were within normal limits.

Imaging:

Ultrasound- to confirm the presence of mass

The green arrow shows the trachea and the yellow arrow shows a nodule in the right thyroid gland.

Impression of the US:  The ultrasonography (US) showed a solid, irregular margin nodule, 2.5 cm in size, in the right lobe of the thyroid. accompanying microcalcifications and hypoechogenicity

 

Ultrasound-guided Fine-needle aspiration biopsy: suspicion for malignant papillary carcinoma

A single fine-needle aspiration biopsy of the right lobe nodule revealed microscopic appearance of a papillary carcinoma showing well-formed papillae and cells with ground glass nuclei.

 

DDX: Papillary Thyroid Cancer

Management

Treatment depends on the type of cancer and prognosis depends on staging, with a 99% 5-year survival with locally confined, less than 1 cm papillary carcinoma.

• Always involves complete or partial removal of the thyroidwith chemotherapy and external beam radiation reserved for anaplastic thyroid cancer

 

 

Sources:

1. https://www.cancer.net/cancer-types/thyroid-cancer/diagnosis
2. https://www.endocrineweb.com/conditions/thyroid-cancer/thyroid-cancer-symptoms
3. https://www.endocrineweb.com/conditions/thyroid-cancer/papillary-cancer
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10. https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-1-133