A Comprehensive Case Study on a Postpartum Patient with Thyroid Storm and Papillary Thyroid Cancer

QUESTION

Allison is a 35 year old G2P1 F who is currently 6 weeks post partum.  She was induced for IUGR at 38 wks and delivered vaginally without complications.  This morning, her husband found her difficult to rouse and confused so he called EMS.  The husband states she has been anxious since the birth of her child, but believes this is expected because the baby was small at birth and pediatricians are concerned about his growth.  Allison had nausea, vomiting and diarrhea for two days prior.  Her milk supply has diminished and she has now switched to formula feeding.  The husband states they have not traveled recently and have no sick contacts.  Allison is still on maternity leave so she has been home caring for the infant.  The husband has returned to work.

What additional history questions should we ask the husband at this time?  Let’s come up with ten.

What initial nursing assessments should be performed?

Upon further questioning you learn:

PMH vitilaigo, hyperlipidemia, asthma

PSH none

SH: Allison works as a CRNA at a local hospital where she has been employed for 9 years.  She walks for exercise but has been exercising less since the birth of the baby.  She does not smoke or drink alcohol.  She follows a vegan diet.  She has been married to her husband Chad for 4 years.  The couple recently purchased a new home right next to Allison’s mother which has been both a source of support but also stress at times.

ALL None

Meds simvastatin 10 mg daily, albuterol inhaler PRN

At this time, Allison is only minimally responsive to painful stimuli. She is unable to answer orientation questions and just keeps repeating her husband’s name.  The nurse notes redness to her eyes and swelling around her eyelids. She has thyromegaly with +bruit and +thrill.  There  are no palpable nodules.  Heart rate is rapid and irregular. Lungs have diffuse crackles bilaterally. Vital signs are as follows:

HR 145 bpm

BP 120/76 mmHg

RR 32 bpm

Temp 101°F

SpO₂ 89% on 4L nasal cannula

What should the nurse’s first action be?

What diagnostic tests do you anticipate will be ordered?

Her HR goes up to 155.  AN EKG demonstrates atrial fibrilation.  The patient becomes even less responsive and she is intubated for airway protection.  She is transferred to the ICU.  Her lab results are below:

Na 144 pH 7.33 TSH <0.005 (0.2-4.2 is normal)

K 5.0 pCO₂ 48 WBC 14K

Mg 1.0 HCO₃^– 24 Hgb 12.5

BUN 11 pO₂ 190 Hct 38%

Cr 0.7 Lactate 3.2 Plt 450K

What is going on with Allison?

She is treated with IV fluids, a beta blocker, and methimazole 20 mg PO BID.  She starts doing much better clinically, she is in normal sinus rhythm and she is able to be extubated.  She is transferred to the floor on hospital day 4 and now has the following test results:
TSH <0.005, T4 9.0 (normal)

Thyrotrophin receptor antibody (TRAb) 30 (high)

ALT 150 U/L (normal is up to 42)

AST 102 u/L (normal is up to 37)

Alk phos 306 U/l (60-306)

Nuc med thyroid scan demonstrates diffuse increased uptake equal throughout the thyroid gland with no areas suggestive of a hot or cold nodule.

Thyroid sono demonstrates enlarged, hypervascular thyroid with no discrete nodules

What is concerning about her laboratory results and what could be causing it?

What do you think is the etiology of her thyroid condition

What are her treatment options?

Allison opts to proceed with a total thyroidectomy.  Post operatively, she complains of pins and needles in her hands and on exam, you note a positive Chvostek’s sign and positive Trousseau’s sign.

What surgical complication might Allison be experiencing?

What treatment should be ordered?

What patient counseling should be provided to a patient who has just undergone a total thyroidectomy?  Any other meds we need to discuss?

Allison’s surgical pathology returns as follows:

Enlarged thyroid gland

R lobe tumor 0.5 papillary thyroid cancer, encapsulated, no lymphatic or angioinvasion.

Central neck lymph nodes 1/11 positive for papillary thyroid cancer.  The tumor focus is 0.5 mm.

ANSWER

A Comprehensive Case Study on a Postpartum Patient with Thyroid Storm and Papillary Thyroid Cancer

Introduction

This case study presents the complex medical journey of Allison, a 35-year-old postpartum woman, who experienced a sudden onset of confusion and altered consciousness. As we delve into Allison’s medical history, laboratory results, and clinical manifestations, we aim to understand the underlying causes and treatment options for her condition.

Patient History and Initial Nursing Assessments

Upon assessment, Allison displayed symptoms of altered mental status, rapid heart rate, and diffuse crackles in the lungs. Her medical history included vitiligo, hyperlipidemia, and asthma, while her social history revealed her occupation as a CRNA, vegan diet, and recent purchase of a new home. Her vitals indicated hyperthyroidism, with a rapid irregular heart rate, elevated body temperature, and low oxygen saturation.

First Action and Diagnostic Tests

Given the severity of Allison’s condition and abnormal vital signs, the nurse’s first action was to intubate her for airway protection and transfer her to the ICU. Subsequent EKG results confirmed atrial fibrillation, and laboratory tests revealed a low TSH, elevated T4, and high TRAb levels. These findings pointed to a diagnosis of thyroid storm, a life-threatening complication of hyperthyroidism.

Etiology of Thyroid Condition and Treatment Options

The etiology of Allison’s thyroid storm was attributed to Graves’ disease, an autoimmune disorder causing excessive production of thyroid hormones. Her treatment options included IV fluids, beta-blockers, and methimazole to stabilize her condition. After her successful recovery in the ICU, Allison decided to undergo a total thyroidectomy.

Surgical Complication and Treatment

Following the thyroidectomy, Allison experienced pins and needles in her hands, and positive Chvostek’s and Trousseau’s signs, indicative of hypocalcemia due to parathyroid injury during surgery. The appropriate treatment would involve calcium supplementation and close monitoring of calcium levels.

Patient Counseling and Medication

After a total thyroidectomy, patient counseling should emphasize the importance of lifelong thyroid hormone replacement therapy to maintain thyroid hormone levels. Additionally, calcium and vitamin D supplements are necessary to prevent hypocalcemia. A patient undergoing thyroidectomy should also be educated about the potential complications, including the need for lifelong medical follow-ups.

Pathology Results

The surgical pathology revealed a 0.5 mm papillary thyroid cancer focus in Allison’s right lobe, with no lymphatic or angioinvasion. Furthermore, one out of eleven central neck lymph nodes tested positive for papillary thyroid cancer.

Conclusion

Allison’s case highlights the intricate interplay of hyperthyroidism, thyroid storm, and papillary thyroid cancer in a postpartum patient. Through prompt diagnosis, comprehensive treatment, and patient counseling, healthcare providers can achieve successful outcomes for patients like Allison. This case study underscores the importance of vigilance and prompt management in complex medical scenarios, ultimately improving patient care and outcomes.