Diarrhea CC A 63 years old male with complaint of diarrhea since 7 years ago In 1387 11 years ago the patient was referred to endocrinologist due to left thyroid enlargement and ID: 935934
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Slide1
Endocrine Grand round
IN THE NAME OF GOD
Slide2Diarrhea
CC
Slide3A 63 years old male with complaint of diarrhea since 7 years ago
In 1387
(
11
years ago) ,the patient was referred to endocrinologist due to left thyroid enlargement and a 2.5 *1.5 cm nodule was detected in left thyroid lobe and FNA was done.
PI
Slide4FNA report was benign follicular nodule and
repeated FNA in annual
F/u was
the same.
After 4 years (1391) size of nodule increased (3*3cm) and FNA of nodule documented follicular lesion and surgical resection was
recommended.
Slide5In 1391, severe
watery diarrhea
[(
8-10
( times/day, high volume, without abdominal pain and weight loss ] was started.In 1392,left lobectomy and isthmectomy was done and
according to pathology report of MTC
, total thyroidectomy was performed 2
weeks
later.
Slide62 weeks after surgery, tumor
markers of MTC show
normal calcitonin (
Ctn
) with high CEA level.After surgery , diarrhea improved. in annual F/U after operation , CEA and Ctn level and imaging w/u
were
normal until 1396.
Slide7In 1396, diarrhea recurred and the patient
complained
of
watery diarrhea
3-4 times/daily , high volume without abdominal pain, after meals. Serum Ctn was increased to 55 pg/ml.
Imaging w/u showed
a 27*18 mm nodule in bed of left lobe thyroid and
FNA
documented a benign
follicular
nodule.
Slide8regarding to elevated tumor marker and symptomatic (diarrhea) the patient underwent left cervical
mass
resection(1396/11)
pathology
and IHC showed MTC. Diarrhea disappeared until 4 months after surgery.
Slide9Ctn level ,two months
after surgery
decreased
to 17
pg/ml. After 4 month of surgery, diarrhea recurred with the same pattern and Ctn
level
was 95 pg
/ml 8
months after surgery in
1397.
Slide10Imaging w/u showed left cervical lymphadenopathy
.
The patient
underwent
left neck radical L.N Dissection (3th operation )in 1397/9 with report of L.N involvement with MTC.
Slide11After 2.5 months of surgery, serum
Ctn
was not reduced
and
was 252 pg/ml. Diarrhea was continued.Imaging w/u ( 97/12) showed left bed of thyroid nodule (2cm) without pathologic
LAP.
Slide12In 1398,
diarrhea
progressed
(6 times/day) with rise
of serum Ctn (450 pg/ml) and 4 th surgery (left neck mass resection) was done in about 1 month ago.
Pathology
report was
fibrofatty
and muscular
tissue involvement with MTC
.
10 days after
surgery,
Ctn
level
reached
to
966 pg/ml, diarrhea continued with partial improvement by Loperamide. He denies weight loss over the period.
Slide13NephrolithiasisHemorrhoid
BPH
HTN
(-)
DM (-)PMH
Slide14Thyroidectomy
Neck L.N
dissection
PSH
Slide15PenicillinAmoxicillin
AH
Slide16Smoker (-)Addict (-)
HH
Slide17Hypothyroidism in his sister and mother
FH
Slide18Levothyroxine 100 mcg DailyASA 80 Daily
DH
Slide19Constitutional symptoms: Negative
Skin :
Negative
Head and neck (and Ears, nose, mouth, throat) :
NegativeLimbs , back and Joints : : Negative
Cardiovascular:
Negative
Respiratory:
Negative
Gastrointestinal:
diarrhea
Genitourinary:
ROS
Slide20ConsciousThe apparent age is proportional to the calendar's age
ill(-)
Toxic(-)
GA
Slide21BP : 110/70 mmHg
T : 37.1
RR : 12
PR :
80 BMI : 20 Kg/m2Vital sign
Slide22Conjunctiva: NL / not pale
Sclera not icteric
Neck : surgical scar
Heart: S1 and S2 /
w.o heart murmurLungs: clear /w.o wheeze ,crackleAbdomen: soft / no tendernessLimbs: NL /w.o cyanosis, clubbing, edema, nl
pulses
PHYSICAL EXAM
Slide2396.12.17
Blood
biochemistry
9.8
Ca
3
P
normal
LFT
0.435
TSH
168.2
Ferritin
1.78
ng/ml
CEA
17.8
pg
/ml
Calcitonin
Slide2497.12.7
Hematology
5.32
WBC
6.50
RBC
17.4
Hb
51.8
Hct
79.7
MCV
26.8
MCH
33.6
MCHC
15.8
RDW
158
PLT
15.2
PDW
11.5
MPV
RBC Morphology
+
Aniso
Sedimentation
Rate
2
ESR
Slide25T4
T3
TSH
DATE
8.1
1.15
1.35
87.6.6
0.7
6.1
4
92.4.16
1.25
8.4
8.05
92.4.25
2.1*
0.02
93.2.7
*
1.38
6.08
96.10.5
0.43
96.12.17
1.15
10.35
0.18
97.3.5
1.01
8.43
0.97
97.6.7
97.6.27
8.4
1.1
0.72
97.8.13
Slide26CEA ng/ml
Ctn
pg
/ml
DATE
90
88.4.13
120
89.9.17
138
90.9.23
37.64
2.6
92.4.11
17.17
3.6
92.4.25
1.5
1.49
93.2.7
3.95
55.4
96.10.5
1.78
17.8
96.12.17
95
97.6.7
86.6
97.6.27
16
97.3.5
78.2
97.8.13
16.48
252
97.12.7
451
98.1.21
966
98.2.9
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