A 42-year-old woman is evaluated on postoperative day 1 following a total thyroidectomy fo… — USMLE Step 2 CK

A 42-year-old woman is evaluated on postoperative day 1 following a total thyroidectomy for a multinodular goiter. She complains of new-onset tingling around her lips and in her fingers. Her temperature is $37.6^\circ\text{C}$ ( $99.7^\circ\text{F}$ ), blood pressure is $118/76\text{ mmHg}$ , pulse is $88/\text{min}$ , and respiratory rate is $14/\text{min}$ . Physical examination reveals a clean, well-approximated surgical incision without swelling. Brief twitching of the ipsilateral facial muscles is elicited when her cheek is tapped just anterior to the earlobe. Laboratory studies show:

Laboratory test	Result
Serum calcium	$7.2\text{ mg/dL}$
Serum albumin	$4.0\text{ g/dL}$
Serum free T4	$0.7\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$ )
Serum TSH	$4.2\text{ \mu U/mL}$ (Normal: $0.5-5.0\text{ \mu U/mL}$ )

Which of the following is the most appropriate next step in the management of this patient?

Administration of intravenous calcium gluconateAnswer
B
Initiation of oral levothyroxine therapy
C
Administration of broad-spectrum intravenous antibiotics
D
Computed tomography scan of the neck
E
Measurement of serum intact parathyroid hormone level

Answer

Administration of intravenous calcium gluconate

The correct answer addresses the acute, symptomatic hypocalcemia that frequently complicates total thyroidectomy due to inadvertent injury or removal of the parathyroid glands. Symptoms such as perioral tingling and a positive Chvostek sign (facial muscle twitching when tapped) indicate severe neuromuscular irritability. This is a medical emergency that requires immediate administration of intravenous calcium (e.g., calcium gluconate) to prevent life-threatening complications such as tetany, laryngospasm, and cardiac arrhythmias.

Step-by-Step Solution

Analyze the patient's postoperative presentation.

The patient developed new-onset perioral and fingertip tingling on day 1 after a total thyroidectomy.

Identifying the timing and nature of symptoms is crucial for recognizing postoperative complications.

Interpret the physical examination findings.

Twitching of facial muscles upon tapping the cheek indicates a positive Chvostek sign.

The Chvostek sign is a classic clinical manifestation of neuromuscular irritability due to hypocalcemia.

Correlate clinical findings with laboratory data.

Serum calcium is markedly low at

7.2\text{ mg/dL}

, confirming the diagnosis of acute hypocalcemia.

Total thyroidectomy carries a high risk of inadvertent parathyroid gland injury, devascularization, or removal.

Determine the appropriate management.

The patient requires urgent administration of intravenous calcium gluconate.

Symptomatic hypocalcemia (paresthesias, positive Chvostek sign) is a medical emergency that must be treated immediately with IV calcium to prevent progression to severe tetany, laryngospasm, or seizures.

Key Concept

Management of Postoperative Hypocalcemia

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