VCU DEATH AND COMPLICATIONS CONFERENCE. Brief Overview of Case Diagnosis: Papillary thyroid cancer...
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Transcript of VCU DEATH AND COMPLICATIONS CONFERENCE. Brief Overview of Case Diagnosis: Papillary thyroid cancer...
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VCUVCUDEATH AND DEATH AND COMPLICATIONS COMPLICATIONS CONFERENCECONFERENCE
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Brief Overview of CaseBrief Overview of Case
Diagnosis:Diagnosis: Papillary thyroid cancerPapillary thyroid cancer Primary hyperparathyroidismPrimary hyperparathyroidism
Procedure:Procedure: Total thyroidectomy, neck exploration and Total thyroidectomy, neck exploration and
parathyroid biopsy parathyroid biopsy Complication:Complication:
Error in diagnosis and hypocalcemiaError in diagnosis and hypocalcemia
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Clinical History
HPI: 11 yo boy
6 months of vomiting Thought to be an infectious etiology Placed on antibiotics.
Workup Extensive GI workup
Was diagnosed with gastritis – placed on Prevacid
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Medical History
PMH: Gastritis Recurrent emesis Undescended testis
SurgHx: Bilateral orchipexy @ 4 yo Tympanostomy tubes @ 2 yo
Meds: Prevacid Keflex
Allergies: NKDA
Labs: Calcium: 13.9 PTH: 508 Vit D: 13.3 Calcitonin normal Serum metanephrines normal
SocHx: Nephrolithiasis Parathyroidectomy GM, GGM
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Medical History
Physical Exam: Vitals: T 36.2 HR 93 BP 108/65 RR 22 O2 100% RA WT 27.9
kg Gen: NAD HEENT: Trachea midline. No palpable mass
Studies: Thyroid US showed 1.5 cm right inferior thyroid pole Sestamibi scan tracer uptake in inferior right thyroid pole FNA: papillary carcinoma
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Hospital Course
Jan 18th: Admitted for vomiting and hypercalcemia
Jan 19th & 20th: Thyroid US/sestamibi scan and FNA showed papillary carcinoma
Jan 25th -27th: To OR for total thyroidectomy, neck exploration and parathyroid biopsy Intraop PTH: 552.4 > thyroidectomy > 21.5 > 9.2 > 5 Calcium: 14.6 > 11.4 > 10.5 > 9.5 > 8.7 > 8.6 > 8.3 Discharged Jan 27th with calcium 1250 mg tid, synthroid, calcitriol
Jan 30th
Admitted to hospital for dizziness, knee pain, increased lower extremity tone
Ca 6.4, Mag 1.8, K 2.4
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Analysis of Complication
• Was the complication potentially avoidable?– Error in diagnosis: No– Hypocalcemia: Possibly yes. Calcium level trending
down • Would avoiding the complication
change the outcome for the patient?– Yes. No readmission for hypocalcemia
• What factors contributed the complication?– Error in diagnosis of papillary thyroid cancer
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In 2007, National Cancer Institute organized NCI Thyroid Fine Needle aspiration state of science conference.
Goal was to establish a guideline and system of nomenclature for the interpretation of Thyroid FNA.
Became known as Bethesda System for reporting cytopathology
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Using Bethesday System Retrospective review 1992 – 2009 of
patients undergoing FNA for suspicious lesion
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