45 F with Cervical Myelopathy secondary to papillar carcinoma thyroid

 Chief complaints

A 45 / F who is a housewife by occupation and is native of west Bengal came with

•c/o weakness of lower limbs since 3 months

•c/o inability to walk since 1 & 1/2month

•c/o pain and inability to extend her right lower limb since 1&1/2 months

History of present illness: 

•Patient reported to have noticed a thyroid swelling 18 yrs ago, which was initially 1 x 1 cm in size , gradually increased to current size of 5 x 7 cm

•3 months ago she started having difficulty in positioning her feet while walking and even had slippage of footwear.

•2 months ago she slipped and fell in bathroom and fractured her right ankle joint for which she received treatment from a local hospital

•1 month prior to admission patient lost her ability to walk and has been using wheelchair since then to get around. 

•Patient complains of both upper and lower backpain radiating to her hip joints with stiffness of muscles of inner part of both thighs associated with dragging type of pain radiating along the inner part of thigh more while stretching her lowerlimbs and more on the right side.

•patient also complained of inability to lie down in supine position as it caused pain in her lower limbs and cannot sit for a long time in the same position

•She is not able to extend her right lower limb completely and her lower limbs have become thinner as compared to 2 months ago

•patient also gave of history of constipation and passing bloody stools when straining to pass hard stools

•h/o recent weight loss of 1-2 kg in last 2 months with lower limbs becoming thinner than before.

Past history : 

•Patient has had similar complaints of both upper and lower backpain radiating to both hip joint since 1&1/2 yrs ago and has been using over the counter pain relief medications

•Patient had gallstone removal surgery 6 yrs ago


Personal history : 

Appetite - normal

Diet - mixed

Bowel and bladder movements - constipation+, inability to feel while passing urine 

Sleep - reduced quality of sleep for the past 2 months due to pain 

Addictions - patient consumes 2 pans per day for the past 6 yrs


GENERAL EXAMINATION

The patient is conscious, cooperative, coherent, and well oriented to time, place, and person

Pallor +, no icterus, cyanosis, clubbing or generalized lymphenopathy 

Vitals

Afebrile

BP 100/70 mmHg

PR 78 bpm

Spo2 99 % @ room temperature

GRBS 119 mg/dl



CNS EXAMINATION

Patient is conscious

Higher mental functions are intact

Speech is intact

Signs of meningeal irritation are absent

Cranial nerves - NFAD

MOTOR SYSTEM

Upper limb.          R.          L

 TONE                    N.         N

 POWER

       DELTOID.        4+.      4+

       BICEPS.          5+.      5+

       TRICEPS.        5+.      5+

       Lumbricals.    5+.      5+

REFLEXES 

                 B              3+.     3+

                 T.             3+.      3+

                 S.             2+.      ABSENT


lowerlimbs.                       R.            L

TONE.                                ↓↓            ↓↓

POWER

EXTENSORS OF HIP.       3+.          3+

FLEXORS OF KNEE          3+.          3+

EXTENSORS OF KNEE.   3+.          3+

PLANTAR FLEXION         3+.          3+

DORSI FLEXION.              3+.           3+


REFLEXES

             KNEE JERK.          3+.           4+

            ANKLE JERK         4+.           4+

            (ankle clonus present)

            PLANTAR.          Extensor  Extensor

ABDOMINAL REFLEX - ABSENT BELOW UMBLICUS









SENSORY SYSTEM.        

                             UL.             LL

                           R.       L.    R.    L

FINE TOUCH.   N.      N.    ↓    ↓

CRUDE TOUCH N.     N.   ↓    ↓

TEMP.                 N     N.    ↓    ↓

( Patient's attender gave a h/o incidentally finding that patient's response to warm temperature was delayed when they placed a cup of hot tea on her ankle)

PAIN.                  N.    N.    ↓    ↓  


PROPRIOCEPTION -LOST UPTO HIP JOINT


VIBRATION                     R.                  L

Medial malleolus.       6 sec.          5 sec

Lateral malleolus.       3.38 sec     4 sec

Patella.                          5 sec.         7 sec

Radial prominence.     6 sec.        6 sec

Clavicle.                          4 sec.         6 sec

On palpation stiffening of muscles of medial and posterior compartments of both thighs

spinal tenderness present at D12 level

Gait could not be assessed

Thyroid swelling present on the left side of neck





CVS : S1, S2 HEARD

RR : BAE +, NVBS

P/A : SOFT, NT


PROVISIONAL DIAGNOSIS

COMPRESSIVE MYELOPATHY 2° to ? Thyroid malignancy


INVESTIGATIONS

OUTSIDE  REPORTS







Outside MRI REPORT 






HB - 10

Tlc - 6200

MCV - 30.9

MCH - 65.7

MCHC - 32.4 

PLT COUNT - 1.10

SMEAR - microcytic hypochromic anaemia


Cr. : 0.7

Urea : 19

Na+ 140

K+ 4.1

Cl- 102


TB : 0.86

DB : 0.20

AST : 28

ALT : 18

ALP - 147

TP : 7.0

ALB: 3.8


RBS : 107

SEROLOGY : -VE

Surgery opinion taken









SOAP NOTES 13/9/21

S

•c/o weakness of lower limbs 

•c/o inability to walk 

•c/o pain and  inability to extend her right lower limb


O

Pt is c/c/c

BP 120/80

PR 82

CVS -S1,S2 +

R/S - NVBS+

P/A - SOFT

CNS  - HMF - NORMAL

SPEECH -NORMAL

POWER        R.              L

             UL    4/5.       4/5

             LL.    3/5.       3/5

TONE

            UL       N.           N

            LL       ↓↓.           ↓↓

REFLEXES

           B.    T.       S.      A.       K.          P

R.       3+.   2+     +.      3+.      3+.       Extensor

L.       3+.   2+     +.      3+.      3+.       Extensor


A

Compressive myelopathy 2° to ? Thyroid malignancy


P

USG NECK DONE 




FNAC DONE - results awaited


X RAYS

 CHEST







FNAC slides






SOAP NOTES 14/9/21

S

•c/o weakness of lower limbs 

•c/o inability to walk 

•c/o pain and inability to extend her right lower limb 
• However patient feels better in terms of pain relief



O

Pt is c/c/c

BP 120/80

PR 82

CVS -S1,S2 +

R/S - NVBS+

P/A - SOFT

CNS - HMF - NORMAL

SPEECH -NORMAL

POWER R. L

             UL 4/5. 4/5

             LL. 3/5. 3/5

TONE

            UL N. N

            LL ↓↓. ↓↓

REFLEXES

           B. T. S. A. K. P

R. 3+. 2+ +. 3+. 3+. Extensor

L. 3+. 2+ +. 3+. 3+. Extensor


GAIT



A

Compressive myelopathy 2° to vertebral metastasis secondary to ? Thyroid malignancy



P

USG NECK DONE 
FNAC DONE - results awaited
Orthopedic surgeon opinion taken



Surgery review opinion






SOAP NOTES 15/9/21

S

•c/o weakness of lower limbs 

•c/o inability to walk 

•c/o pain and  inability to extend her right lower limb


O

Pt is c/c/c

BP 120/80

PR 82

CVS -S1,S2 +

R/S - NVBS+

P/A - SOFT

CNS  - HMF - NORMAL

SPEECH -NORMAL

POWER        R.              L

             UL    4/5.       4/5

             LL.    3/5.       3/5

TONE

            UL       N.           N

            LL       ↓↓.           ↓↓

REFLEXES

           B.    T.       S.      A.       K.          P

R.       3+.   2+     +.      3+.      3+.       Extensor

L.       3+.   2+     +.      3+.      3+.       Extensor


A

Compressive myelopathy 2° vertebral lesions at level of T12 2° to ? Thyroid malignancy


P

Oncologist opinion taken






USG ABDOMEN DONE 



USG GUIDED FNAC
Microscopic picture of thyroid papillary follicular structure

Giant cell with multiple nuclei

 Hypercellularity

Chewing gum colloid - classic of papillary
 carcinoma thyroid 



SOAP NOTES 16/9/21

S

•c/o weakness of lower limbs 

•c/o inability to walk 

•c/o pain and inability to extend her right lower limb



O

Pt is c/c/c

BP 120/80

PR 82

CVS -S1,S2 +

R/S - NVBS+

P/A - SOFT

CNS - HMF - NORMAL

SPEECH -NORMAL

POWER R. L

             UL 4/5. 4/5

             LL. 3/5. 3/5

TONE

            UL N. N

            LL ↓↓. ↓↓

REFLEXES

           B. T. S. A. K. P

R. 3+. 2+ +. 3+. 3+. Extensor

L. 3+. 2+ +. 3+. 3+. Extensor



A

Compressive myelopathy 2° to ? Thyroid malignancy



P
FNAC REPORT



Gynecological review was taken


20/9/21
Patient was consulted with surgical oncologist who asked for a neurosurgeon opinion.
Neurosurgery opinion was taken and pt was adviced for decompression surgery but patient was unwilling and opted for palliative care.
Patient is being referred to MNJ for palliative care with plan of radiotherapy then Total thyroidectomy after which Radioactive Iodine therapy shall be planned.

Follow up at MNJ






2/10/21

The patient received EBRT total dose 30 Cy ---> 3Cy/ # from 22/9/21 to 2/10/21
Patient tolerated well 

4/10/21

The patient got a pre-anesthetic checkup (PAC) done  prior to total thyroidectomy


5/10/21 
Surgical profile was done


6/10/21






7/10/21
A cardiology opinion was taken to get a 2D ECHO and fitness to undergo surgery




CT scan was done




9/10/21
USG neck was repeated



10/10/21
S. Ca level - 9.7

12/10/21
The patient underwent total thyroidectomy with full neck dissection 

CECT revealed 
  • a lytic lesion with soft tissue component @ D4 + D12 + sternum
  • lung metastasis
  • 3 x 3 x 2 cm on left lobe 
  • level IV node enlarged to size 4.4 x 3 x 2 cm
Advised
  • 200 mCi  I-131 in the first week of December
  • T.Eltroxin 125 mcg OD from next day
  • Stop T.Eltroxin in the first week of November
  • T.Wysolone 10 mg tid - start in last week of November
13/10/21 & 14/10/21

POD -2  notes



20/10/21
Post thyroidectomy histopathological report of the biopsy specimen

S Ca2+ - 8 mg/dl

21/10/21

S. Ca2+ - 7.1 mg/dl























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