PATIENT NO. 20 (continued) Follow-Up: Since discharge the patient has been asymptomatic and apparently euthyroid even though his thyroid therapy (3 mg levothyroxine daily) has been sporadic. PATIENT NO, 64 No recurrence of thyroid nodules has been noted. AGE SEX 41 F HOSPITAL DATE Hospital of Medical Research Center, BNL June, 1965 This 41 year old Marshallese woman was admitted to the hospital for evaluation of a thyroid nodule that was discovered during the 1965 annual medical survey of the Rongelap people. History of Present Illness: A 1 cm nodule was discovered in the right lobe of the thyroid gland of this woman in March, 1965. It was firm, non-tender, and no cervical lymph nodes were palpable. She was one of a group of 64 Rongelap people who had been exposed to fallout 1l years ago. She had received an estimated dose of 175 rads of whole body gamma exposure and in addition radiation exposure to her skin and some internal absorption of radioactive materials. Absorption of radioiodines from the fallout gave an estimated dose to the thyroid gland of 150- 160 rads, in addition to the 175 rads from gamma radiation. She had early nausea and vomiting believed to be associated with her radiation exposure and her blood elements were depressed to about one-half normal levels. She developed "beta burns" of the skin beginning about two weeks after exposure, mainly on the back of her neck. These lesions healed within several weeks and her blood elements returned to near normal levels by about one year after exposure. Since that time she has remained in relatively good health with no serious illnesses or injuries. 4 She has had nine children, four of them born since the fallout exposure. She has apparently remained euthyroid. A PBI taken in March was 10.0 ugh (high normal for the Marshallese) and serum cholesterol in 1958 was 249 mgi%. Physical Examination: The patient was a well nourished, well developed female of about her stated age of 41. Pterygia were noted in the right eye. In the right lower pole of the thyroid there was a deeply fixed 1 cm nodule that moved with the thyroid on swallowing. The overlying skin was not attached to the nodule. The nodule was very hard but not tender and no other nodules were palpable. Regional adenopathy was not noted. The blood pressure was normal. There were no other significant findings on physical examination. Laboratory and X-Ray Data: Thyroid Work-up revealed the following: Iodine fractionation: total iodine 8.6 pg%, iodoprotein fraction 4.5 weg%, thyronine fraction (T4 + T3 iodine) 3.4 ug%, PBI 7.5 wgt, serum cholesterol 239 mg% (esters 183 mg%). Basal metabolic rate -27%. Thyroxin autoantibodies titer under 1:16. Thyroid scan showed large ''cold'' nodule replacing the lower pole of the right lobe of the thyroid gland with nodularity also involving the left lobe, lower pole area. Chest x-ray showed no active disease. Thyroid uptake study using 1327 showed a 6-hour uptake of 22.3% with urinary excretion of 33%. After three days of treatment with TSH (I1.M.) thyroid uptake had increased to 33% at 5-1/2 hours. PBI 8.0 wg%. Except for slightly Low RBC (3,300,000) and hemoglobin (11.6 gmx), the blood count was normal. Urinalysis was negative and the following blood chemistry studies were negative: bilirubin, cephalin flocculation, transaminase, Ca, P, thymol turbidity, FBS, BUN, COo, Na, K. Alkaline phosphatase was slightly low (1.4 units); the globulin fraction of proteins was slightly elevated (4.26 gm%). 102 Lal