A 36 yr old woman mrs. Prema, homemaker from madampakkam belonging to lower socioeconomic class presented with chief complaints of swelling in the front of neck for the past 2 months.
HISTORY OF PRESENTING ILLNESS
? The patient was apparently normal 2 months back after which she noticed swelling in the front of neck,
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- -insidious in onset
- -initially small in size gradually progressed to current size.
? not associated with pain
? Difficulty in swallowing for past 1 month more for solid foods
? No h/o breathlessness
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? No h/o hoarseness of voice
? No h/o dyspnea/stridor
? No h/o syncopal attack
? No h/o suggestive of horner's syndrome
? No h/o weight loss/weight gain
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? No h/o diarrhoea/constipation
? No h/o heat/cold intolerance
? No h/o insomnia/sleep disturbances
? No h/o oligomenorrhea/menorrhagia
? No h/o excessive sweating, diplopia
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? No h/o tremors, muscle weakness
? No h/o palpitations, chest pain, pedal edema
? No h/o loss of weight, loss of appetite
? No h/o cough with hemoptysis,
? No h/o bone pain
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? No h/o swelling elsewhere in the body
PAST HISTORY
? No h/o similar complaints in the past
? No h/o previous surgery or hospitalisation
? No h/o DM/HT/TB/asthma/epilepsy/jaundice
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? No h/o neck irradiation in childhood
? No h/o allergy to drugs/food
PERSONAL HISTORY
? Consumes non veg diet
? Normal bowel and bladder habits
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? Not an alcoholic/smoker
? No addictive habits
? Consumes iodinized salt
? Consumes too much cabbage, soyabeans, sea food
MENSTRUAL HISTORY
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? Age at menarche - 14
? Regular cycles
? Normal flow 3/28
? not associated with clots
FAMILY HISTORY
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? No significant family history
GENERAL EXAMINATION
- Patient is conscious, oriented, moderately built and nourished.
- No pallor
- No icterus
- No cyanosis
- No clubbing
- No pedal edema
- No generalised lymphadenopathy
- No signs of hyper/hypothyroidism
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VITAL SIGNS
PR-76/min, regular in rhythm, normal volume, no specific character, no radioradial, radiofemoral delay, felt in all peripheral pulses, nature of vessel wall normal
RR-18/min, thoracoabdominal type
BP-130/70mm Hg measured in right upperarm, sitting posture
Afebrile
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LOCAL EXAMINATION
? After getting consent from the patient, she was examined in sitting posture under bright light
? EXAMINATION OF THYROID
INSPECTION
? A swelling of 6*5cm in the front of neck, butterfly shaped, in the region of thyroid, extending 2cm from suprasternal notch, upper border 2cm from oblique line of thyroid cartilage, extends upto anterior border of sternocledomastoid on both sides.
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? Surface appears to be smooth, skin over swelling normal, well defined margin, lower border can be seen,
? No scar, sinuses, dilated veins, visible pulsation
? Moves with deglutition
? No movement with protrusion of tongue
? Trachea appears to be in midline
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PALPATION
? Not warmth, not tender
? Inspectory findings of site, size, shape, extent are confirmed
? 2 nodules palpable on either lobe of thyroid gland.
nodule on left side: single nodule of size 1*1 cm hemispherical in shape present on left lobe.
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EXTENT- 4cm above sternum
-0.5 cm from midline
-2cm from thyroid cartilage
nodule on right side: another nodule of size 1*2 cm hemispherical in shape present in right lobe.
EXTENT-2cm from sternum
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-0.5cm from midline
-3cm from thyroid cartilage
- both nodules are soft to Firm in consistency, surface smooth, margin- well defined, mobile, moves with deglutition
- Trachea in midline
- Kochers test -ve
- Berry's sign -ve
- Carotid pulsations felt on both sides equally
- No palpable thrill
- No regional lymph nodes palpable
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PERCUSSION
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normal resonant note over manubrium sternum
AUSCULTATION
no bruit
OTHER SYSTEM EXAMINATION
RS: normal vesicular breath sound heard, no added sounds
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CVS: s1 s2 heard, no murmur
CNS: no focal neurological deficit
ABDOMEN: soft, non tender, no organomegaly, no free fluid, hernial orifice free
SPINE AND CRANIUM: normal
DIAGNOSIS: non toxic.non malignant, multinodular goitre in euthyroid state, with pressure symptom
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MANAGEMENT
INVESTIGATIONS:
ROUTINE:
blood: complete hemogram-TC,DC,Hb%, ESR,BT,CT
urine: sugar, albumin
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xray chest, ecg
SPECIFIC:
xray neck, CT neck
blood urea, sugar, creatinine
usg neck, radioactive iodine uptake study
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ENT examination,
thyroid profile, thyroid antibodies, thyroglobulin
thyroid scan
FNAC
indirect laryngoscopy
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TREATMENT
TOTAL THYROIDECTOMY
SUBSTITUTION THYROXINE 0.2 mg/day
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This download link is referred from the post: MBBS Final Year Case Presentation (Clinical Case Examination, Discussion and Treatment)