Specialty : Thyroid Disease in Pregnancy (Surg + Obst)
Examiner : Prof S & Prof Z
Case Summary :
29y.o Malay Lady
G2P1 at 22/52
Presented with neck swelling currently for 6/12.
First notice 1/12 before went to seek treatment.
Swelling at the right neck, painless, initially size of a marble, gradual increase in size.
No compressive Symptoms
+ Hyperthyroidism – irritability, mood swing, heat intolerance, increase in appetite, proximal weakness
No Risk factor : no family hx, not from endemic area, no hx of radiation.
At the moment, she has done TFT. Scheduled for U/S and FNAC tomorrow. Not on any antithyroid.
1 month after noticing the lump, patient found out she was pregnant. Currently, at 22/52 of POA. No active complain other than morning sickness. MGTT once due to weight gain (2kg in 1 month). Result : unknown
Questions :
1. Present your history and summarise it.
2. Show me how you examine the thyroid. (how much are you going to expose patient?)
3. Summarise your neck examination.
4. What is your diagnosis and its differentials. (I said toxic adenoma. DDx – dominant nodule in MNG, thyroid malignancy)
5. Why do you say toxic adenoma?
6. How are you going to investigate the patient? TFT, U/S, FNAC.
7. What do you expect in TFT? Primary hyperthyroidism, low TSH, high t3 and t4.
8. If patient is euthyroid, what can be the diagnosis? Malignancy and benign thyroid
9. What other biopsy can you do? FNAC and Tru cut. He asked ever heard of tru-cut in thyroid? Then I changed my mind to excisional biopsy.
10. If it is malignancy, what can it be? papillary and follicular. The most likely? Papillary
11. How are you going to manage if it is malignancy? My plan is to go for op which is total thyroidectomy, keep patient euthyroid by giving PTU since patient is pregnant.
12. How soon? I dunno. A.S.A.P?
13. Complications of thyroidectomy.
14. What are the nerves that can be cut. Recurrent laryngeal nerve – unilateral hoarseness. Bilateral – stridor.
15. What to do if patient has stridor? I answered dilate the vocal cord? Stenting?
16. What antithyroid drugs that you know? Carbimazole and PTU.
17. Which one cross placenta? I said carbimazole. PTU doesn’t. Prof said, both can.
18. What are the things that you be worried of Hyperthyroidism to pregnancy? I answered IUGR, oligo. He said ok.
19. What is the complication that can occur that will delay delivery? I have no idea. Answer : fetal goiter.
20. Other complication to anticipate? I said hypertension in pregnancy. (OK). Others? Thyroid storm (after hinting)
21. How are u going to manage thyroid storm? Steroid, iv hydration, antipyrexia, ptu and potassium iodide.
22. Can you breastfeed her post-delivery? I said can.
23. Does the antithyroid drugs be passed in the breast milk? I said no. answer is YES. The process is called weaning down since the mother has been on antithyroid throughout the pregnancy.
24. If patient is 30/52 and you found out it is malignant, what is your plan? I said do op. he said yes, do C-Section. (HAHAHA padahal I meant thyroidectomy)
25. If patient is 8/52? This is a controversial question. I said keep the pregnancy. But I think Prof Zainurrashid said, terminate it. Prof Shaker said, wait until 12/52 baru op patient. I am confused here.
TIPS :
1. Request buku merah from the patient.
2. Ask as many as you can from the patient. Even for the current plan. It may help you with the answer.
3. I was lucky the fact that I only have to present neck examination and not the whole physical examination (though I did BP, reflex and all).
1 DOWN, 2 MORE TO GO! WISH ME LUCK PEEPS!!
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