vcu death and complications conference. brief overview of case diagnosis: papillary thyroid cancer...
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VCUVCUDEATH AND DEATH AND COMPLICATIONS COMPLICATIONS CONFERENCECONFERENCE
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
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
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
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
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
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
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
Using Bethesday System Retrospective review 1992 – 2009 of
patients undergoing FNA for suspicious lesion