Case Presentation: Thyroid Swelling

Case presentation of Thyroid Swelling detailing history taking and examination in long case pattern in General Surgery

1. CASE PRESENTATION Thyroid Swelling Dr Snigdh Garg 3 rd Yr Academic Junior Resident Dept. Of General Surgery, DMCH

2. Case History Name- Babita Devi Age/Sex/Religion- 40/F/H Residence- Kishanpur , Samastipur Occupation- Housewife Chief Complaint - painless swelling in front of neck in midline since last 7 years.

3. History of Present Illness - My patient was apparently well 7 yrs back, then she developed a swelling over front of her neck in midline, of size about 3cm x 2 cm, which gradually increased in size to its present dimensions of about 12 cm x 6 cm over left side, 14 cm x 5 cm over right side and 6 cm x 3cm in middle part of neck. The swelling is painless and moves with deglutition but not with tongue protrusion. Patient doesn’t have any hoarseness of voice, difficulty in swallowing solid or liquid foods or difficulty in breathing. There is no history of sudden increase in size of swelling.

4. History of Past Illness - patient doesn’t have history of any significant illness in past. Patient doesn’t have any history of Diabetes, Hypertension, Asthma or Tuberculosis. Patient has no history of radiation exposure to head, neck and chest. Personal History - patient is a non vegetarian and consumes mixed Indian diet. Patient does not smoke, doesn’t consume tobacco or alcohol. Patient’s sleep and appetite are normal. Patient’s bowel and bladder habits are normal too. Patient has no history of change in weight or intolerance to heat or cold. Patient’s socioeconomic status is average. Patient is G5P4 and has regular menses. She had undergone bilateral Tubal ligation 10 years ago.

5. Family History - patient doesn’t have history of any similar illness in family except in a distant relative. There is no history of similar illness in her neighborhood. Both of her parents died of natural causes. Drug History - patient has no history of drug intake. Patient doesn’t have any known allergies.

6. Clinical Examination

7. General Survey Patient is conscious, cooperative and oriented with time, place and person. Patient has average built and normal gait. Her Karnofsky Score is 90 and ECOG Performance Score is 0. Patient has no pallor, icterus , cyanosis, clubbing, lymphadenopathy , engorgement of neck veins or edema. Pulse- 82 bpm , regular, normovolumic . BP- 128/74 mmHg Respiratory Rate- 14/min Afebrile No pigmentation or scar marks were present.

8. Local Examination Inspection : A butterfly shaped swelling is present in front of neck in midline in thyroid region extending bilaterally up to Sternocleidomastoid muscles, superiorly up to Thyroid cartilage and inferiorly up to Suprasternal notch with dimensions as follows- Left side- 12 cm x 6 cm Right side- 14 cm x 5 cm Middle- 6 cm x 3cm The swelling moves with deglutition and lower margin of the swelling can be visualized on deglutition. The swelling doesn’t move on tongue protrusion. There is venous prominence over the swelling without any visible pulsations. No signs of sympathetic trunk involvement (Horner’s Syndrome) are present.

9. Palpation : The temperature over neck swelling is normal, swelling is non tender. The swelling has a smooth surface with defined margins. It has a soft consistency with no pulsations or thrills. The swelling has mobility in horizontal plane without independent upward mobility and its lower margin can be palpated. The swelling is not fixed to overlying skin. Circumference of neck at most prominent part is 42 cm. Trachea is central in position and Kocher’s Test for tracheal compression is negative. Carotid pulsation are palpated bilaterally at normal site and hence Berry’s Sign is negative. None of the cervical lymph node groups were palpable.

10. Percussion : On percussion over manubrium sterni a resonant note is obtained. Ausculation : No bruit is audible over the neck swelling.

11. Examination for Toxic Signs : There is no tremor in hands or tongue. Patient doesn’t have proximal muscle wasting, i.e., Plummer’s sign is negative. There is no Pretibial myxedema or Thyroid acropachy . Eye Signs- There is no exopthalmos , diplopia or chemosis . Dalrymple’s sign, Naffziger’s sign, von Graefe’s sign, Joffroy’s sign, Mobius sign and Stellwag’s sign are negative. Examination for Retrosternal Prolongation : Pemberton’s sign is negative.

12. Systemic Examination Nervous System - patient is conscious, alert , cooperative; speech and gait are normal; all cranial nerve functions are normal. Tone, power & coordination of upper limb and lower limb is normal. Superficial and deep sensations as well as reflexes are normal. Cranium and spine are normal. Cardiovascular System - apex beat is in normal position, no heave or thrill is present. 1 st and 2 nd heart sounds are audible, no palpitations or murmurs are present. Respiratory System - shape and movement of chest are normal. Trachea is central in position and there is no tenderness over chest. Both lungs are resonant on percussion with liver and cardiac dullness in normal positions. Breath sounds are vesicular and equal on both sides. No crepitations or ronchi are present.

13. Abdominal Examination - Inspection- shape is normal, umbilicus is central in position; no scar or pigmentation is present, no expansile impulse over hernial sites is present. Palpation- temperature is normal, no tenderness or guarding, no swelling is present. Percussion- liver dullness is present. Auscultation- bowel sounds are present.

14. Case Summary This 40 year old female presented with a painless swelling in front of her neck in midline which has enlarged gradually over last 7 years. She doesn’t have any hoarseness of voice, dysphagia or dyspnea and the swelling moves with deglutition but not with tongue protrusion. There are no symptoms pertaining to nervous, cardiac or respiratory systems. She has a normal appetite, sleep pattern, bowel habit and menstrual cycle. There is no history of similar illness in her family or neighborhood.

15. On examination, General survey is normal. On local examination, a butterfly shaped swelling in front of neck in midline extending up to Sternocleidomastoid bilaterally, thyroid cartilage superiorly and suprasternal notch inferiorly is present, suggesting it to be a thyroid swelling. It has a smooth surface, soft consistency, is non tender, mobile and not fixed to underlying or overlying structures. Trachea is central and bilaterally carotid pulsations are palpable at normal site without any cervical lymph node enlargement or signs of sympathetic trunk involvement. There are no signs of thyrotoxicosis or retrosternal prolongation.

16. Provisional Diagnosis - This is probably a case of Nontoxic Colloid Goitre . Differential Diagnosis Colloid Nodule involving both lobes Nontoxic Multinodular Goitre Chronic Thyroiditis Carcinoma of Thyroid

17. Investigations Thyroid profile- TSH, T3 and T4 USG and FNAC of Thyroid gland Baseline Investigations- CBC, BT, CT, LFT, KFT, Blood Sugar(fasting and PP), Routine examination of Urine, Chest radiograph PA view, ECG.

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