Case Write Up_harmeet_multinodular Goitre

CASE WRITE UP Department of Surgery Cyberjaya University College of Medical Sciences

MULTINODULAR GOITRE Name: Harmeet Kaur a/p Daleep Singh Matric No.: 0908-1235 Year/Group: Year 3/Group 5 Supervisor: Mr Ahmed Awil Adam Core Component

Given Marks

History Physical Examination Investigation Provisional Diagnosis/Differential Diagnosis Discussion: Identify problems, management and progress of patient References

1. HISTORY

1.1 Demographic Data

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Patient Name: Maslina Bt Ahmad Age: 66 years old Sex: Female Origin: Batu Pahat, Johor Date of admission: 25th December 2011 Date of Clerking: 30th December 2011 Place of clerking: Putrajaya Hospital

1.2 History of Presenting Illness

Chief complain: Madam Maslina presented to the Emergency Department following an episode of shortness of breath which lasted about half an hour on 25th December 2011 Madam Maslina’s history dates back to year 2000 where she first noticed a neck swelling on both sides of her neck. It was relatively small sized, with the right side being bigger than the left side. It was not painful and felt like multiple, small, seed like swellings (in her words) on her neck. It was soft and mobile too. There was no discharge or ulcers at the site of swelling and neither was it itchy or associated with any eczema. She noticed the swelling a few months after she had delivered her 4th child. At that time, she also had lethargy and had lost weight, about 5kg in the span of 3 months. She also had headache on and off. Her food intake was the same though, with no increase or decrease in appetite. She did not eat much seafood either. She had no heat or cold intolerance, difficulty in breathing or dysphagia at that time either. She did not notice any overt sweating or tremors as well. There was also no change in voice, diarrhea, palpitations or swelling anywhere else on her body. Her systemic review was unremarkable at that time.

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Due to her neck swelling, she went to Batu Pahat hospital at that time (year 2000) to see the doctor and was told that she most probably had a problem with her thyroid gland but nothing was done and no medications were given either. The swelling gradually increased in size over the years but she did not think that it was serious as she didn’t notice it becoming bigger until year 2009 where she was scheduled to do a surgery (thyroidectomy) in Batu Pahat hospital but the surgery was postponed as her thyroid hormone levels were high. Hence she was discharged with medications to stabilize her thyroid hormone level and was asked to come back again after a year and a half. She defaulted her follow up though. Now, in December 2012, she presented to the ED of Batu Pahat hospital with SOB which occurred at rest and lasted till she got to the ED, which was about half an hour. It had a sudden onset and was associated with syncopy which occurred while she was on the way to the hospital. The syncopy lasted about a few minutes though and she gained consciousness in the ED. She even had fever 1-2 days prior to admission which was intermittent in nature. She did not take any medications to relieve her fever though. She had no prior episodes of dyspnea, orthopnea or paroxysmal nocturnal dyspnea before this. She did not have any leg swelling or chest pain and did not have dysphagia prior to admission either. Her neck swelling was now much bigger in size, about 15cm in length. She had lost more weight over the years, gradually though but did not remember the amount. Systemic review was unremarkable. In Batu Pahat hospital, they took a long time to intubate her as it was difficult to do so and referred her to Putrajaya Hospital on that day itself.

1.3 Past Medical History

She was diagnosed to have hypertension in 2009 during her routine checkup. She does not have any other chronic illnesses though. She had not gone for any surgery before this either. 1.4 Family History

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Her parents have passed away. Her father had asthma while he was alive while her mother had hyperthyroidism, hypertension and diabetes mellitus. She has 4 siblings whose ages range from 40-50 something years old. Her brother has hypertension and diabetes mellitus while her sister has rheumatoid arthritis and diabetes mellitus. Her other younger sister has hyperthyroidism too. She is married with 5 children whose ages range from 5-20 years old. They are all healthy. Hence, the ones with similar problems as her are her younger sister and mother.

1.5 Drug History

She used to take medications but only from year 2009. She takes a medication to reduce her thyroid hormone levels and is on anti-hypertensives. She does not remember the name of her drugs though. She is not compliant to her anti-hypertensives though as she takes them when she has headaches only. She is not allergic to any drugs and has not taken any traditional medicine previously.

1.6 Social History

She does not smoke nor consumes alcohol. She lives with her children and is generally well looked after. She is married with 5 children and her husband is still working as a contractor. She is a caterer and has a food business of her own.

2. PHYSICAL EXAMINATION

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2.1 General Inspection

Post-op

On general inspection, she was conscious and was sitting up comfortably on her bed and was using a nasal prong. She was not in respiratory distress and was alert. She was orientated to time and space. She also had a branula inserted on the dorsal part of her hand and she was on CBD. Her palms were slightly moist. There was no clubbing or any other nail changes. There was slight tremor though. She was not pale or jaundiced and there was no central or peripheral cyanosis. She was slightly dehydrated though. Her face is not edematous.

2.2 Vital signs

Upon admission:

BP: 158/94 mm/Hg Heart rate: 103/min RR: 35/min

Post – op

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BP: 130/85 Heart rate: 84/min RR: 16/min

2.3 Neck examination

Pre-op

Upon inspection of her neck, there is a swelling on both sides of the neck, with the right side being bigger than the left. It extends just above the suprasternal notch and lies deep to the sternoclaidomastoid muscles. The skin over the swelling is not red; there are no scars or eczema. There are slightly dilated veins visible on either side of the swelling. There are no sinuses or discharge from the swelling. There are no visible pulsations either. The swelling moved upward with swallowing. Upon palpation, the swelling was of normal temperature and was not hot. The right lobe measured 20x25 cm while the left lobe was 15x10cm. The swelling was not tender, firm and mobile. It’s surface was nodular and the tracheal rings were not palpable at the suprasternal notch. There were no thrills noted on the superior poles of the thyroid gland. Carotid pulse could be palpated, and it was strong and present. Upon percussion over the manubrium of sternum, dullness was noted. Upon auscultation of the superior poles of the gland, no bruits were noted. There were no lymph node enlargements.

Post-op

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Post operatively, she has a fresh scar on her neck with visible stitches and no dressing. It is a horizontal scar measuring about 10cm. There is a catheter inserted at the operative area to drain blood from it. Her voice is now hoarse and she can barely whisper out words.

2.4 Systemic review:

Eyes: slight lid retraction and infrequent blinking pre operatively, no exopthalmos and she can converge her eyes, no ptosis Cardiovascular system: unremarkable Respiratory system: unremarkable Neurological system: unremarkable GI system: unremarkable Pulses: all present and strong Legs: No pretebial myxedema, no pitting edema

3. DIAGNOSES

3.1 Provisional Diagnosis

Multinodular goiter causing airway obstruction

3.2 Differential Diagnosis 7

1. Thyroid carcinoma 2. Graves’ disease 3. Lymphadenopathy

4. INVESTIGATIONS

4.1 Pre-Op (25th December 2011)

1. Full Blood Count

Component

Values

Normal Range

Total White Blood Cells

13.8

(4-11) x 109 cells

Red Blood cells

4.1

(3.8-5.5) x 1012 /L

Heamoglobin

12.2

(12-18) g/dL

Heamatocrit

35.5

(34-50) %

MCV

85.2

(83-100) fL

MCH

29.3

(27-32) pg

MCHC

34.4

(32-37) g/dL

RDW

14.7

(10-15) %

Platelet count

146

(150-400) x 109/L

Neutrophils

12.7

(2.5-7.5) x 109/L

Lymphocytes

0.5

(1.0-3.5) x 109/L

Monocytes

0.6

(0.2-0.8) x 109/L 8

Eosinophils

0

(0.04-0.4) x 109/L

Basophils

0

(0.1.0.1) x 109/L

2. Renal Profile

Component

Values

Normal Range

BUN

7.5

(2.5-6.4) mmol/L

Na

141.6

(132-144) mmol/L

K

4.40

(3.5-4.5) mmol/L

Cl

111.4

(95-105 ) mmol/L

Creatinine

80

(53-115) μmol/L

3. Coagulation Profile

Component

Value

Normal Range

PT

12.7

12.4-14.7

INR

1.146