Case Presentation on Thyroid Swelling-2.pptx

Case

1. Case Presentation on Thyroid Swelling Moderators Presented by- Dr. Anisha Singha Dr. Anjay Baishya 3 rd Year PGT Associate Professor, Dept of General Surgery. Dept of General Surgery. Dr. Rajib Bora Registrar, Dept of General Surgery.

2. Patient Particulars Name: Mrs. XYZ. Age: 40 years. Sex: Female. Religion: Hinduism. Address: Uzan Bazaar, Guwahati. Marital status: Married. Occupation: Housewife. Date of admission: 19/1/2022. Date of examination: 19/1/2022.

3. Chief Complaints Swelling over the neck for 2 years 6 months.

4. History of Present Illness She first discovered the swelling on the left side of the neck approximately 2 years and 6 months back while taking a bath . It was insidious in onset. It was initially the size of a pea which gradually increased to attain the present size similar to the size of a betelnut . The swelling is not with associated pain, redness, fever and sudden increase in size.

5. It is not associated with Difficulty in swallowing Hoarseness or change of voice. Difficulty in breathing. Weakness or trembling of limbs Increased fatiguability . Awareness of one’s own heartbeat.

6. Increased irritability. Intolerance to heat or cold. Increased sweating. Bulging of eyes Loss of vision Redness of eyes Double vision. Blood in sputum, cough, evening rise of temperature .

7. Her sleep and apetite are normal. Her bladder and bowel habits are normal. There is no history of weight gain or loss.

8. Past History The patient has no history of similar illness in the past neither during puberty nor during her pregnancy . There is no history of hypertension, Diabetes Mellitus, Tuberculosis or any other medical or surgical illness in the past . There is no history of surgical intervention in the past. There is no history of radiation exposure to the head and neck region or the chest.

9. Family History There is history of a similar neck swelling in her maternal aunt. However, she did not visit any doctor ,hence, it was not diagnosed and no treatment was done for the same. Both her parents died due to senile age and not any illness . There is no history of similar swelling in her siblings ( 2 brother 1 sister) or her cousins. At present there are eight members in her family and they all are apparently enjoying good health.

10. Personal History She is a non vegetarian by diet and consumes an average Assamese meal everyday . She consumes iodised salt . She has no history of consumption of excessive cabbage or other goitrogens . The patient has been consuming betelnut for the past 20 years . She does not consume tobacco, neither is she a smoker or an alcoholic.

11. Menstrual and Obstetric History. She attained her menarche at the age of 14 years and menopause 3 years back . The patient had regular cycles at interval of 30-31 days for a duration of 5 days . She is a multipara with four children, three sons and one daughter, all of them were delivered vaginally and they were all uneventful.

12. Socio economic history Belongs to lower middle class family. Lives in a kuccha house. Source of water: Tube well which is consumed after boiling.

13. Drug history There is no history of consumption of any anti thyroid medications in the past . There is no history of intake of any chronic medications.

14. Allergy History The patient is not allergic to any substance ingested, inhaled or that she has come in contact with till date.

15. Immunization History Not documented however it is confirmed by presence of BCG scar on left upper arm.

16. General Physical Examination. Patient is examined in a well lit room after taking consent. Patient is well oriented to time, place and person. Vitals Pulse: 64 beats per minute, normal in volume, character with no radio-radial or radio-femoral delay. All peripheral pulses are palpable. Blood pressure: 136/88 mm Hg measured over the Left upper arm in lying down position. Respiratory rate: 12 breaths per minute, thoraco abdominal. Temperature : 37 ° Celsius.

17. Appearance: Healthy. Decubitus: Of choice. Built: Average. Nutrition: Adequate. Height : 152.4 cm, Weight: 55 kg BMI: 23.7 kg/m 2 Hair: Normal in colour and texture.

18. Pallor: Absent. Icterus: Absent. Cyanosis: Absent. Oedema : Absent . Dehydration: Absent . Tongue: Moist. Clubbing: Absent. Neck glands : Not palpable. Neck Veins: Not engorged. Tremors : Absent.

19. Demonstration of Tremors

20. Local Examination. Inspection: A swelling of 3*2.5 cm i s seen over the left side and front of the neck . It is ovoid in shape . The surface appears smooth . It moves with deglutition,however , it does not move with protrusion of the tongue . Extent: Both the upper and lower margins are clearly seen.

21. Skin over swelling is normal . There is no visible pulsation. Pemberton’s sign is negative . There are no venous prominences over the neck or chest wall.

22. Swelling moves with deglutition

23. Swelling does not move with protrusion of tongue

24. Demonstration of Pemberton’s Sign( Negative in this case)

25. Palpation The temperature over the swelling is not raised . There is no tenderness . The swelling is palpable in left lobe of the thyroid extending in the front of the neck approximately 1 cm to the right of midline medially and laterally over the anterior border of the left sternocleidomastoid muscle in the horizontal axis. In the vertical axis, the lower margin of the swelling is 1.5 cm above the medial end of left clavicle and upper margin is 4 cm below the mandible.

26. The lower extent of the swelling is palpable and the finger can be insunated between the swelling and the sternal notch. It is ovoid in shape . Size: 3*2.5 cm . The surface is smooth and margins are well defined .

27. It is firm in consistency . There is no fixity to skin . The swelling is not fixed to the underlying structures and is mobile. No thrill or pulsation is felt over the swelling . The trachea rings are palpable and it lies in the midline.

28. The carotid pulse is palpable on both the sides. Berry’s sign: Negative . Cervical lymph nodes: Not palpable . Oral examination: Normal.

29. Palpation of Thyroid Swelling By Lahey’s Method Palpation of Thyroid Swelling from behind the patient.

30. Palpation of Thyroid Swelling By Crile’s Method Examination of lower extent of the swelling

31. Palpation of Trachea Examination of Carotid Pulse

32. Examination of eye There is no exophthalmos . Lid lag( Von Graefe’s sign) is absent. Stellwag’s Sign- Absent. Joffroy’s Sign- Absent. Mobius Sign- Absent. Dalrymple’s Sign- Absent. Opthalmolegia - Absent. Chemosis - Absent.

33. Demonstration of lid lag Test for Ophthalmoplegia

34. Percussion Over Manubrium Sterni : Resonant. Auscultation No bruit heard.

35. Percussion over Manubrium Sterni to check for Retrosternal extension.

36. Respiratory System The chest movement is bilaterally symmetrical Trachea is in midline Normal vesicular breath sounds heard No added sounds.

37. Cardiovascular System The precordium is normal. First and second heart sounds heard normally. No murmur or any added sounds heard.

38. Central Nervous System The patient is conscious, alert, communicative and well- oriented to time, place and person. All cranial nerves are intact. Motor and sensory system are found to be normal.

39. Summary The patient a 40 year old female presented with a swelling over the left side of the neck for past 2 and half years with g radual increase in size with no history of pain and compression symptoms. There i s no history suggestive of hypo/ hyperthyroidism. On examination, a 3*2.5 cm a ovoid swelling i s palpable over the left lobe of thyroid with firm consistency, smooth surface, well defined margins and no fixity to underlying structures or skin. The swelling moves up and down with deglutition . There are no toxic signs or clinical evidence of retrosternal extension.

40. Provisional Diagnosis This is a case of solitary thyroid nodule involving the left lobe of the thyroid gland in euthyroid status.

41. Thank You