Download MBBS Final Year Surgery Case Presentation Thyrotoxicosis Clinical Examination Discussion and Treatment

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NAME: MRS. CHANDRA

AGE: 35 YRS

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SEX: FEMALE

OCCUPATION: HOME MAKER

ADDRESS: KORUKKUPET

CHIEF COMPLAINTS

PROMINENT EYES for past 1 yr

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HISTORY OF PRESENTING ILLNESS

• The patient was apparently normal 1 yr back after that she noticed prominent eyes. Associated with increased dryness.
• No h/o itching, redness of eyes or blurred vision.
• No h/o diplopia
• H/O loss of weight (15 kgs in one yr)

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• No h/o loss of appetite
• H/o intolerance to heat
• H/o excessive sweating
• H/o anxiousness and nervousness
• H/O tremors

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• H/o diarrhea on and off episodes, 2-3 times a day, semisolid stools, not blood stained, no mucus, no passage of worms, not fowl smelling.
• No h/o vomiting
• H/o muscle weakness - difficulty in climbing up stairs.
• H/O palpitations
• No h/o any swelling

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• No h/o fever

No History suggestive of pressure symptoms like

• No h/o dyspnoea
• No h/o dysphagia
• No h/o change in voice

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• No h/o suggestive of Horner's syndrome
• No h/o syncope

No History suggestive of hypothyroidism like

• No h/o weight gain inspite of poor appetite
• No h/o constipation

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• No h/o cold intolerance
• No h/o easy fatiguability
• NO h/o sudden increase in size

No history suggestive of malignancy like:

• No h/o loss of appetite and weight loss

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• No h/o bone pain
• No h/o jaundice
• No h/o cough with hemoptysis
• No h/o headache, convulsions, seizures

PAST HISTORY

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• No h/o similar complaints in the past
• No h/o previous hospitalisation
• Not a known case of diabetes, hypertension, asthma, epilepsy, tuberculosis, jaundice, ischaemic heart disease
• No h/o irradiation
• No h/o previous surgery

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• No h/o drug intake

PERSONAL HISTORY

• Non - vegetarian diet
• Patient consumes adequate salt
• No h/o excessive intake of goitrogens

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• H/o altered bowel habits: diarrhea on and off episodes
• No h/o altered sleep pattern

MENSTRUAL HISTORY

• Attained menarche at 15yrs of age
• Irregular cycles for the past 2 yrs, 4/70 days, less flow, not associated with clots or dysmenorrhea

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• Last menstrual period: 17-10-2017

FAMILY HISTORY

No history of similar complaints in the family

ALLERGIC HISTORY

No significant allergic history

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Summary:

35 year old female, came with the complaints of prominent eyes for the past one year, palpitations, nervousness, weight loss inspite of good appetite, diarrhea, oligomennorhea probably involving pathology of thyroid gland.

GENERAL EXAMINATION

• Conscious, oriented
• Moderately built and nourished

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• No pallor
• Not icteric
• No cyanosis
• No clubbing
• No pedal edema

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• No peripheral significant lymphadenopathy

EYE SIGNS

• Eyeballs are prominent
• Dalrymple sign: upper sclera is seen above the limbus
• Stellwag sign: infrequent blinking of eyelids

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• Von Graefe sign: lid lags behind on asking to look up and down
• Enroth sign: oedema of eyelids and conjunctiva
• Gifford sign: difficulty in everting upper eyelid

• Intention tremors present
• Hands are warm and moist

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• No pretibial myxoedema, pruritis, palmar erythema, thinning of hair, dupuytren's contracture.
• No corneal conjunctival ulcers.

VITAL SIGNS

• BP: 130/80mm Hg measured in left upper limb in sitting posture.
• Respiratory rate: 17/min thoracoabdominal

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• Pulse rate: 102/min regular in rhythm, normal in volume, no specific character, no radio-radial and no radiofemoral delay, no vessel wall thickening, felt in all accessible peripheral vessels.
• Temperature: 98° F (afebrile)

LOCAL EXAMINATION OF THE NECK

After getting consent from the patient and explaining her the procedure the patient is examined

Examination in the front of neck in the region of thyroid

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INSPECTION

• No visible enlargement in the thyroid region
• No visible nodules
• Surface appears to be smooth
• Skin over the region of thyroid normal

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• No scar, no sinus, no dilated veins
• No visible pulsations
• Trachea appears to be in midline

PALPATION

• Warm, not tender

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• Mild diffuse enlargement of thyroid gland
• Smooth surface
• No nodules
• Soft in consistency
• Moves up on deglutition

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• Does not move with protrusion of tongue
• Lower border palpable
• Becomes more prominent on performing pizzilo method

• Plane of the swelling: deep to deep fascia
• Carotid pulsation felt against the upper border of thyroid cartilage equal intensity on both sides (Berry's sign negative)

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• No palpable thrill
• Trachea is in midline
• No other swellings present
• Kocher's test: no stridor

PERCUSSION

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• No retrosternal dullness

AUSCULTATION

• No bruit heard

EXAMINATION OF LYMPH NODES

No palpable lymph nodes in the neck region.

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OTHER SYSTEM EXAMINATION:

• RS: Normal vesicular breath sounds heard, no added sounds
• CVS: S1, S2 heard, no murmur
• CNS: No focal neurological deficit
• Abdomen: soft, non tender, no organomegaly, no free fluid, hernia orifices free.

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• Spine and cranium normal.

DIAGNOSIS

A Case of primary thyrotoxicosis

INVESTIGATION

• Baseline investigations: CBC, TC, DC, Hb%, ESR, BT, CT

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• Blood urea, serum creatinine
• Urine: sugar, albumin
• Chest x-ray
• ECG
• LFT, RFT

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Specific investigations

• Thyroid profile: TSH, T3, T4, FREE T3, FREE T4
• USG neck
• X-ray neck
• Sleeping pulse rate

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• Fine needle aspiration cytology.
• Laryngoscopy
• Thyroid stimulating Autoantibodies
• Radio active iodine uptake

TREATMENT

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• TOTAL THYROIDECTOMY