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A 46-year-old woman who was previously healthy was diagnosed with papillary thyroid carcinoma and referred for total thyroidectomy with neck dissection. Shortly after the surgery, the patient developed headache, tingling, muscle cramps, and leg spasms.
On physical examination the patient’s blood pressure was 102/74 mm Hg and heart rate was 62 beats/min. While measuring blood pressure, the patient developed carpal spasm. The neck examination revealed a normally healing surgical wound with no evidence of inflammation or infection. Gentle tapping on the cheek near the mouth resulted in facial twitching.
Laboratory findings revealed low albumin-corrected calcium levels of 7.3 mg/dL (normal range 8.5 to 10.5 mg/L) with parathyroid hormone (PTH) at the low end of the normal range. In addition, phosphate level was 4.8 mg/dL (normal range 2.5 to 4.5 mg/dL) and magnesium and vitamin D levels were in the normal range.
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A 36-year-old woman with a past medical history of fibromyalgia presented to her general physician for a regular check-up. The patient reported that her mother was recently diagnosed with hypothyroidism and requested that her scheduled blood work include thyroid function tests. The patient said she has been well; even her symptoms related to fibromyalgia had been under control. Her only complaint was some hair loss, but it had slightly improved since she began using over-the-counter supplements 3 months before her appointment.
On physical examination, the patient appeared to be healthy: her vital signs were normal, there was no evidence of thyroid eye disease, tremor, or tachycardia; and her thyroid gland was not enlarged. Blood work completed the same day revealed normal complete blood count and liver and kidney function tests, but thyroid-stimulating hormone (TSH) was low, measuring 0.02 µIU/mL (reference range, 0.4-4.6 mIU/L). Free thyroxine (T4) was measured at 24 pmol/L (reference range, 10-19 pmol/L), and free triiodothyronine was measured at 7.1 pmol/L (reference range, 3.5-6.5 pmol/L). After review of her previous laboratory tests, it was found that her thyroid function tests, including TSH and free T4 levels, were previously normal on several occasions.
In a follow-up visit, the patient denied recent pregnancy, iodine exposure, neck pain or fever, recent acute illness, and symptoms of thyrotoxicosis. In addition, she denied receiving any new medication, specifically amiodarone or lithium.