34 Year old female having lethargy and thyroid disease

This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here after collecting informed patient consent (form downloadable Click Here) by BMJ Elective Student.

Case Summary:

This 34-year-old female presented with sudden hand tremors 3 days back of the initial presentation and intermittent pre-syncope. She had a history of shoulder and neck pain. Her thyroid function was done subsequently with chest X-ray and cervical spine Xray (attached below). She was diagnosed with mild hypothyroidism subsequently after repeated thyroid evaluation done.

We reduced her thyroxine to 50mcg in June 2017 and she was doing fine until 1 month back when she has again developed the same lethargy she was experiencing in March 2017. On March 2017 the lethargy became better by 80% on increasing the dose but the tests became slightly overcontrolled so we reduced it again to 50 mcg which was fine till one month back when she again developed lethargy. So this time instead of jumping up to 75 mcg let's increase it to 62.5 mcg

Prescriptions chronological:

TEST results:

Complete blood count results:

Xray report of Chest P/A views and Cervical spine AP and lateral view:

Comments

57 Year Old female with goiter and thyrotoxicosis

This 57 year olf lafy presented with neck swelling, anxiety and tremor. Her medical information is attached below: We need to take a decision on this lady. To operate or not to operate. Now that our clinical suspicions of thyroticosis have been proved and malignancy not proved (not disproved either) what would be the next best step? Medical management for her thyrotoxicosis or still get an excision biopsy with sub total thyroidectomy (and subtotal thyroidectomy other than disproving malignancy will also become treatment for her hyperthyroidism). So which one should we prefer (if the family has no reservations from their side)?

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