By Ramzi Ajjan, Stephen M. Orme
This booklet offers case stories followed via questions and commentaries for the professional registrar in diabetes and endocrinology, to aid with problem-based studying in the course of their education. The case stories variety from the typical to the infrequent and intricate, proposing a robust beginning for the professional trainee to arrange them for his or her qualifying checks and, extra importantly, for his or her destiny medical consultations.
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Extra resources for Endocrinology and Diabetes: Case Studies, Questions and Commentaries
What are the options now? There is no value in repeating the FNA given the latest cytology result and the increased risk of malignant nodule associated with Graves’ disease. Surgery, typically a lobectomy, is usually required with all Thy3 cytology as it is not possible to distinguish between a benign or malignant follicular lesion with FNA cytology. 2 Cytological classification of thyroid nodules and action required Cytological result of FNA Description Thy1 Non-diagnostica Inadequate sample or artefacts do not allow interpretation Thy2 Non- neoplastica Action Repeat FNA Use ultrasound guidance if not used initially Thy3 Follicular lesion/suspected follicular neoplasm Thy4 Suspicious of malignancy Suspicious but not diagnostic of papillary, medullary or anaplastic carcinoma or lymphoma Diagnostic of malignancy Thy5 Repeat 3–6 months Two thy2 results are generally required to exclude neoplasia Most patients require thyroid lobectomy and should be discussed at an MDT meeting Surgery is usually indicated All cases to be discussed by MDT Surgery is indicated Further management, investigation, radiotherapy, chemotherapy to be discussed by MDT Adapted from Perros  Cysts may be described as thy1 in the absence of epithelial cells and presence of colloid and histiocytes (and clearly described as cysts) or thy2 if benign epithelial cells are also present a tomy, following which she is commenced on levothyroxine 100 μg.
She has a regular tachycardia (120 bpm) with no evidence of heart failure. She has no signs of active thyroid eye disease. The thyroid is moderately and diffusely enlarged with a palpable nodule within the right lobe of the thyroid which is non-tender and mobile. There is no cervical lymphadenopathy. What are the differential diagnoses and how would you proceed at this stage? 1. Toxic adenoma 2. Graves’ disease with a simple nodule 3. Toxic multinodular goitre 4. Graves’ disease with a cold nodule, which may be malignant How would you manage this patient?
An elevated TPO antibody titre is usually seen in PPT. What questions should you ask? How would you manage this patient? Has she previous pregnancies and if so, did she experience similar symptoms in the postpartum period? Is there a family history of thyroid disease or other autoimmune conditions? Has she experienced postpartum depression? What signs do you look for? If she finds thyrotoxic symptoms debilitating, she can be offered treatment with beta blockers. However, she is at risk of entering a hypothyroid phase so her thyroid function and symptoms should be closely monitored, every 4–6 weeks.