CASE 3

Male
52

Anamnesis

Full Family and Personal Anamnesis Covering Endocrine Pathology and Genetics
  • Age/Gender: 52 years, Male
  • Medical History: Diagnosed with hypothyroidism 10 years ago; no history of diabetes or cardiovascular diseases.
  • Family History: Mother had thyroid cancer; father has type 2 diabetes.
  • Medications: Levothyroxine for hypothyroidism.
  • Allergies: No known drug allergies.
  • Previous Surgeries: Cholecystectomy (gallbladder removal) 5 years ago.
  • Lifestyle: Non-smoker, occasional alcohol use, moderate physical activity.

Medications

  • Current Medications: None.
  • Vitamin Supplements: Daily multivitamin.

Allergies

No known allergies.

Previous Surgeries

Appendectomy at age 22.

Previous Neck Surgeries

None.

Symptoms and Aesthetic Discomfort

Description of Local Symptoms and Aesthetic Discomfort

A patient, post-cosmetic dermatological treatment, experiences persistent symptoms including noticeable skin redness, uneven pigmentation, and tactile roughness, leading to significant aesthetic discomfort and concern about the prolonged recovery period.

Thyroid Lab Tests

Report results of thyroid-related tests like TSH, FT3, FT4, AbHTG, AbTPO, and Calcitonine.
  • TSH: 4.2 mIU/L (slightly elevated)
  • FT3: 3.1 pg/mL
  • FT4: 1.5 ng/dL
  • AbHTG: Within normal limits
  • AbTPO: Within normal limits
  • Calcitonin: Normal

Parathyroid Lab Tests

Present findings from parathyroid tests such as PTH, calcium, phosphorus, vitamin D, and calciuria levels.
  • PTH: 55 pg/mL (normal)
  • Calcium: 9.8 mg/dL
  • Phosphorus: 3.5 mg/dL
  • Vitamin D: 30 ng/mL
  • Calciuria: Normal

Ultrasound Finding

Ultrasound reporting main dm of the lobes and isthmus, nodules' description (position, volume, shape, echogenicity, structure (solid, mixed, spongiform, cystic)
  • Main Dimensions: Right Lobe: 4.5 cm, Left Lobe: 4.3 cm, Isthmus: 0.3 cm
  • Nodules’ Description: One nodule in the right lobe, 1.2 cm, solid, hypoechoic

Macro/Microcalcifications

None observed

Trachea Deviation

None

FNAC/CNB Report

  • Fine-Needle Aspiration Cytology: Benign colloid nodule.

Final Comment

  • Patient exhibits signs of early-stage thyroid enlargement with benign characteristics. Current symptoms are mild with no significant tracheal compression or risk factors for malignancy.

Proposal for Treatment

  • Routine monitoring recommended; no immediate surgical intervention required.
  • Follow-up ultrasound and thyroid function tests in six months.
  • Patient education on symptoms indicating the need for re-evaluation.

Neck Pictures

Picture of The Neck (Lateral and Front)