Case Based

Discussion (CBD)
Ebtesam Hoshan Almajed
439003552
 01 02 03
Case Scenario Initial Differential Patient’s History
Diagnosis

04 05 06
Physical Refinement of Investigations
Examination differential diagnosis

07 08 09
Final diagnosis Management Plan Evidence Based
Medicine
 01
Case
Scenario
 Case Scenario

A 19-year-old female known case of IBS

presented to the OP clinic at UMC, complaining

of general fatigue, hair loss, and cold

intolerance started 4 months ago.

 02
Initial
Deferential
Diagnosis
 Initial Deferential Diagnosis

▪ Hypothyroidism

▪ Iron deficiency anemia

▪ Fibromyalgia

▪ Vitamin B12 deficiency

 03
Patient’s
History
 Patient’s History

A 19-year-old Saudi female, resident of Riyadh. History was taken from the
Patient Data patient himself.

Chief Complaints General fatigue, hair loss, and cold intolerance started 4 months ago.

Generalized fatigue even after a good amount of sleep, mild hair loss, poor
concentration, and cold intolerance.
HPI No Hx of bowel habit change, no skin dryness, no Hx of weight gain, no Hx
constitutional symptoms (e.g., fever, night sweat, appetite change, lymph node
enlargement), no low mood or loss of interest.

Past medical & She is a known case of IBS.

surgical history She had no past surgical history nor blood transfusion.

Vitamin D3 5000 I.U. taken orally once a week.

Drug history Multivitamin taken orally daily
 Patient’s History
Allergy No known medicine, food, or environmental allergies.

No history of similar symptoms in any member of the family. No history of

Family History thyroid disease, inherited diseases, or malignancy in her family.

She is single. A 2nd year student studying physics at PNU. Not an active nor
passive smoker. Doesn’t drink alcohol or use illicit drugs. Lives in a villa with
Social History her family. She exercise 3 times a week, not on any special diet. No history of
recent travel.

No menstrual irregularities. She described her menstrual cycle as non-painful

Menstrual History regular cycle that lasts 5 to 6 days with average blood flow.

Systemic review Unremarkable

 Patient’s History

ICEE
Idea She has no idea of what it might be.

Concern She is concerned that these symptoms are untreatable like her IBS.

Expectation To know the reason behind her symptoms.

▪ It affected her grades because of her decreased concentration.

Effect ▪ She can’t exercise like she used to do 4 months ago.
▪ Her hair loss affected her self-esteem.
 04
Physical
Examination
 Physical Examination - (General)

General:
▪ She looks well, fully conscious, oriented to time, place, and
person, & not in acute distress. Average body weight.

▪ Vital signs: Heart Rate 87 beats per minute

Respiratory Rate 14 breaths per minute
Temperature 36.6°C
Blood Pressure 119/78 mmHg
O2 Saturation 100%
BMI 23.9 kg/m2
 Physical Examination - (General)

General:
Hand
▪ Pulse: normal rate 81bpm, regular rhythm.
▪ Nails: No onycholysis, cyanosis.
▪ Dorsum: No fine tremor or muscle wasting.
▪ Palm: No erythema, pallor, sweating or dry palms.
 Physical Examination - (General)

General:
Eyes:
▪ No exophthalmos, lid retraction, lid lag, peri-orbital edema.

Face:
▪ No vitiligo.
▪ No buffy face.
▪ No alopecia.
▪ No thinning of outer 1/3 of the eyebrows.
 Physical Examination - (Focused)
I. Inspection:
▪ No scar nor prominent veins, no rash, no erythema.
▪ Right lower mass.
II. Palpation:
▪ Size: diameter is approximately 4 cm.
▪ Shape: regular shape & with round contour mass at the right lower lobe.
Local Thyroid
▪ Consistency: soft & not palpable.
Examination
▪ Tenderness: not tender.
▪ Mobility: not mobile only upward movement of the thyroid gland during
swallowing.
▪ Thrill: no thrill.
III. Percussion: The manubrium is resonant.
IV. Auscultation: No systolic bruit, no carotid bruit, no venous hum.
 Physical Examination - (Focused)

▪ Site: right lower border of the SCM.

▪ Color: normal same color as the surrounding skin, no transillumination
▪ Temperature: normal.
Local lump ▪ Tenderness: no tenderness.
Examination ▪ Shape & size: The swelling was oval in shape; 2×2 cm.
▪ Surface: smooth surface with well-defined margin.
▪ Consistency: semi-solid.
▪ mobility: mobile.
Physical Examination - (Focused)

Rest of the body systems

were unremarkable
 05
Refinement of
differential
diagnosis
 Initial Deferential Diagnosis

▪ Hypothyroidism

▪ Iron deficiency anemia

▪ Fibromyalgia

▪ Vitamin B12 deficiency

Deferential Diagnosis
 06
Investigations
 Investigations

▪ CBC

▪ Iron profile

▪ Vitamins D & B12

▪ TSH

▪ Thyroid US
Test Items Reference Range Units Results
Red Cell Count 4.00 - 5.40 10^12/L 4.77
Hemoglobin 120 - 160 g/L 126

Haematocrit 0.360 - 0.540 L/L 0.379

MCV 76.0 - 96.0 fL 79.4

MCH 27.0 - 32.0 pg 26.5

MCHC 320 - 350 g/L 334

RDW 11.5 - 14.5 %CV 13.4

Platelet Count 150 - 400 10^9/L 342

Mean Platelet Volume 6.8 - 10.2 fL 8.2

White Cell Count 4.00 - 11.00 10^9/L 4.90
 Test Items Reference Range Units Results

Percent Iron Saturation 15 - 50 % 12

Ferritin 11.0 - 306.8 ng / mL 10.1

Iron 10.7 - 32.2 umol/L 7.7

3.84
Thyroid Stimulating Hormone 0.38 - 5.33 uIU/mL

Vitamin B12 pmol / L 332

Vitamin D25-OH nmol/L 57

▪ Thyroid gland is of average size showing diffuse
heterogenous texture and increased vascularity.

▪ Right lobe shows echogenic small nodule measures

1.2x0.6x0.6 cm.

▪ A large lobulated heterogenous mainly hypoechoic

soft mass with numerous calcifications seen at the
right side of the neck just anterior lateral the right
carotid sheath and abutting the right lobe of thyroid,
measuring 3.5x1.7 cm and showing obvious internal
vascularity.
 07
Final
Diagnosis
 Suspicious

Exophytic Thyroid

Nodule
 08
Management
Plan
 Management plan

Various factors should be considered in management of thyroid

nodule including:
▪ Serum TSH
▪ Clinical risk factor assessment
▪ Size of the nodule
▪ Ultrasound characteristics
▪ Patient preferences
▪ Results of the FNA biopsy
Management plan

▪ Reassurance & addressing patient concerns.

Management plan

▪ Thyroid nodule:

⁘ Fine needle aspiration biopsy (FNA)

⁘ CT scan with contrast

Management plan

▪ Iron deficiency:
⁘ Iron supplement

▪ Education:
⁘ Explain the condition
⁘ Next step of the management
⁘ Compliance to medication & side effects

▪ Follow-up: after 1 week

 09
Evidence Based
Medicine
Thank you!!