HEALTH HISTORY
Biographic Data
68-year-old White female. Born and raised in Columbus, OH. Married to husband for 38 years. Recently retired from nursing job at Wexner Medical Center’s radiology department.
History of Present Illness
A 68-year-old White female with previous untreated chronic non-tender enlarged thyroid gland. She started having back neck pain, an earache, and a sore throat 5 days prior to doctor’s visit, along with feelings of fatigue and malaise for 2 weeks. The patient stated that she has not noticed any changes to her weight; vital signs, height, and weight measurements were taken.
The patient states that her usual diet consists of seafood with yogurt for dessert for lunch and dinner with an occasional glass of wine for dinner.
Past Medical History
The patient was diagnosed with chronic myeloid leukemia (CML) in 2004 and has been taking imatinib mesylate for treatment since diagnosis.
Family History
The patient states that her mother suffered from lupus and her father had type 1 diabetes.
Social History
The patient recently retired from her nursing job, lives with her husband – who also just retired from his engineering job. The patient drinks occasionally and has never smoked. The patient does not go out much because she prefers to stay inside the house under her warm blanket.
Allergies
The patient states that she does not suffer from any allergies.
Medications
Imatinib mesylate since 2004 for CML.
Physical Exam
A physical examination revealed bilateral hypertrophy of the thyroid lobes along with tenderness and firmness. There was no palpable nodule on either gland.
An ultrasound revealed avascular dense areas of both thyroid glands; avascular heterogeneously hypoechoic glands.
A needle biopsy revealed a population of various immune cells; macrophages, plasma cells, centroblasts (activated enlarged B-cells), and lymphocytes. A few epithelial cells with cancer characteristics were noted.
*TPO = thyroperoxidase; Tg = thyroglobulin; TSH = thyroid stimulating hormone; T3 = triiodothyronine; T4 = thyroxine; ESR = erythrocyte sedimentation rate
Vital Signs and Measurements
Height: 159 cm
Weight: 47.8 kg
B/P: 154/75 mm Hg
HR: 98 bpm
RR: 14 / min
Temperature: 36.5 C
Resources:
Hashimoto Disease. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Retrieved from https://www.unboundmedicine.com/ucentral/view/5-Minute-Clinical-Consult/1688185/all/Hashimoto_Disease
Seo, H. M., Kim, M., Bae, J., Kim, J. H., Lee, J. W., Lee, S. A., … Lee, D. H. (2012). A case of painful Hashimoto thyroiditis that mimicked subacute thyroiditis. Chonnam medical journal, 48(1), 69–72. doi:10.4068/cmj.2012.48.1.69