CASE PRESENTATION

I. IDENTITY
Date of hospital entry : 1th March 2017
Name : Mr. R
Age : 58 years old
Gender : Male
Occupation : Farmer
Addres : Kodasari
Religion : Islam
Marital status : Married

II. ANAMNESIS

Main complaint

Patient complain of a lump in his right neck

History of disease

Mr. R came to RSUD Arjawinangun with complain of a lump in the right neck since
10 years ago. The patient said the lump was getting bigger and theres no pain from
the lump but from this last month he feels pain from the lump. The patient not
complain about fever, vomiting, or nausea. Lump do not move.

History of past disease

Mr. R said he never had experienced the same symptoms before. The patient had no
history of surgery.

History of family disease

Mr. R said, there is no family members with the same disease as patient.

III. PHYSICAL EXAMINATION

a. Present Status
Genereal condition : No pain
Awareness : Compos mentis
Blood pressure : 170/80 mmHg
Pulse : 90 x/minute
Breathing : 20 x/minute
Temperature : 36,7 oC
Head
Form : Normocephale, symmetrical
Hair : Gray, no hair fall

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 Eye :Anemic conjungtivas (-/-), icteric schleras (-/-),
light relexes (+/+), isochore pupil right = left
Ear :Normal form, cerumen (-), thympany
membrane intact
Nose :Normal form, septum deviation (-), epitaxis(-/-)
Mouth :Normal

Neck
Enlargement of lymph nodes (-), trachea in the middle, no mass found
Thorax
Lungs pulmonary
Inspection : The chest is symmetrical both left and right
Palpation : Fremitus vocale and tactile are symmetrical,
crepitation (-), tenderness (-), rebound
tenderness (-)
Percussion :Resonance sound in both lung fields
Auscultation :Vesicular abd bronchial sound in the entire lung
field, ronchi (-/-), wheezing (-/-)
Abdomen
Inspection :Flat, symmetrical, mass (-)
Palpation :Tenderness (-), rebound tenderness (-)
Percussion :Tympanity sound in four quadrants
Auscultation :Intestine sound (+)
Extremities
Upper
Muscle Tone : normal
Movement : active / active
Mass :-/-
Strenght :5/5
Oedema :-/-
Lower
Muscle tone : normal
Movement : active / active
Mass :-/-
Strenght :5/5
Oedema :-/-

Genitalia
No abnormalities
b. Localized Status
Regio : Regio Colli Anterior dextra
Inspection : left neck looks more bigger than right Colli
Palpation : Theres mass 4x4x4 on the left neck
c. Laboratory Examination

Test Result Unit

Full Blood

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 Hemoglobin 8.2 gr/dl
Hematocrit 25.7 %
Leukocyte 6.2 10e3/L
Trombocyte 513 10e3/L
Erythrocyte 2.95 mm3
Erythrocyte Indexes
MCV 87.1 Fl
MCH 27.8 Pg
MCHC 31.9 g/dl
RDW 15.5 Fl
MPV 7.0 Fl
PDW 14.6 Fl
Counts (DIFF)
Eosinophil 0 %
Basophil 0 %
Segmen 51.2 %
lymphocytes 35.9 %
monocytes 12.9 %
Stab 0 %
Coagulation
Clotting time 4 Menit
Bleeding time 230 Menit
Hormone
T3 1.74 Mmol/L
T4 77.3 Mmol/L
TSH-s 1.21 uUI/ml
Immunology
HBsAg 0,01
Anti HIV Non reaktif

IV. DIAGNOSIS
Struma Nodusa Non Toxic
V. DIFFERENTIAL DIAGNOSI

Tiroiditis akut
Tiroiditis subakut
Tiroiditis kronis,limpositik (hashimoto),fibrous-invasif ( riedel )
Simple goiter
Struma endemic
Kista tiroid,kista degenerasi

VI. TREATMENT
Operative

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 Tumor Excision
Medicamentosa
Cefazoline 2x1
Ketorolac 2x1
Lansoprazole 2x1
VII. PROGNOSIS
Ad vitam : dubia ad bonam
Ad sanationam : dubia ad bonam
Ad fungsionam : dubia ad bonam

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 LITERATURE REVIEW

A. Definition

Goitre is the enlargement of the thyroid gland that usually occurs because the follicles filled
with colloid excessively. After years of mostly follicles grow larger by forming a cyst and the
gland becomes nodular.

Nodosa non-toxic goitre is an enlargement of the thyroid gland that is clinically palpable
nodules one or more without signs hypertiroidisme.

B. Etiology

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The presence of functional disorders in the formation of thyroid hormones were factors in the
thyroid gland enlargement include:

a. iodine deficiency
In general, patients with goitre disease often found in areas with drinking water and soil
conditions less containing iodine, such as mountainous regions.
b. Congenital metabolic disorder that inhibits the synthesis of thyroid hormones.
1) Inhibition of hormone synthesis by chemical substances (such as substances in the
cabbage, turnips, soybeans).
2) Inhibition of hormone synthesis by drugs (eg thiocarbamide, sulfonylurea and lithium).
c. Hyperplasia and involution of the thyroid gland.
Generally found in pertumbuan period, puberty, menstruation, pregnancy, lactation,
menopause, infections and other stress. Where raises nodularity of the thyroid gland and
disorders that can be a sustainable arseitektur with reduced blood flow in the area.

C. Classification

Struma nodosa can be classified based on several things, namely:

1. Based on the number of nodules; if the number called goitre nodules nodosa only one
solitary (uninodosa) and, if more than one is called goitre multinodosa.
2. Based on the ability to capture radioactive iodine thyroid nodules known three forms,
namely: cold nodules, nodules warm and hot nodules.
3. Based on the consistency; soft nodules, cystic, hard and very hard.

D. Pathophysiology

Iodine is all the main ingredients the body needs for the formation of thyroid hormones.
Materials containing iodine absorbed by the intestines, into the blood circulation and captured
most of the thyroid gland ..
In gland, iodine dioxide into an active form that distimuler by Thyroid Stimulating Hormone
and then incorporated into the thyroxine molecule that occurs in the cell phase colloids.
Molecule compounds that formed in diyodotironin form of thyroxine (T4) and molecular
yoditironin (T3).

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Thyroxine (T4) showed negative feedback regulation of the secretion of Thyroid Stimulating
Hormone and work directly on tirotropihypofisis, being tyrodotironin (T3) is metabolically
active hormone.
Some medications and circumstances may affect the synthesis, release and metabolism of the
thyroid while inhibiting the synthesis of thyroxine (T4) and through negative feedback
stimulation increases the release of TSH by hypofisis gland. This condition causes
enlargement of the thyroid gland.

E. Clinical manifestations

In nodosa nontoxic goiter disease slowly enlarged thyroid. Initially this gland enlarges
diffusely and slippery surfaces. If the goitre is large enough, it will suppress the tracheal area
that can cause interference with respiration and also esofhagus depressed resulting in
swallowing disorders.
Clients do not have any complaints because no hypo or hipertirodisme. Lump in the neck.
Increased metabolism for hyperactive clients with increased pulse rate. Increased sympathetic
like; heart into palpitations, anxiety, sweating, can not stand cold weather, diarrhea,
trembling, and fatigue.
On examination localist status struma nodosa, differentiated in terms of:
1. The number of nodules; one (solitary) or more than one (multiple).
2. Consistency; soft, cystic, hard or very hard.
3. Pain in emphasis; or not there
4. Adherence to the surroundings; present or absent.
5. Enlarged lymph nodes around the thyroid: present or absent.

F. Diagnosis

Non-toxic struma nodosa diagnosis is established based on history, physical examination,

assessment of the risk of malignancy, and inspection penunjang.Pada generally non-toxic
struma nodosa do not have complaints for not adahipo- or hyperthyroidism. Enlarged thyroid
is usually started at a young age and developed into multinodular as adults. Because of its
growth gradually, goitre can be great without symptoms unless a lump in the neck. Most

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patients with struma nodosa can live with strumanya without complaint.
Physical examination

Inspection
Inspection carried out by inspectors who are in front of people who are in a sitting position
with the head or neck flexion slightly ajar. Hen there is swelling or nodules, to note a few
components, namely the location, size, number of nodules, a form of "diffus or small
nodular , the movement when the patient is asked to swallow and palpate the swelling
surface.

Palpation
Examination by palpation method in which patients were asked to sit down, the neck in a
flexed position. The examiner stands behind the patient and palpate the thyroid USING
thumb of both hands on the neck of the patient. $ The hyoid, kartilagotiroid and cricoid until
the second ring trakaea usually easily palpable in the midline.% Incin trachea caudal
increasingly difficult the more palpable because of the trachea leading to dorsal.Pada
swallowing movements, the entire trachea moves up and down. The only structure lainyang
contribute to this movement is the thyroid gland or something that comes darikelenjar
thyroid.

G. Differential diagnosis

Struma nodosa happened to increased demand for the current thyroxine infancy, puberty
lactation, menstruation, pregnancy menopause, infections.
Acute thyroiditis
Subacute thyroiditis
chronic thyroiditis, limpositik (Hashimoto), fibrous-invasive (Riedel)
Simple goiter
endemic goitre
thyroid cysts, cystic degeneration
adenoma
Primary thyroid carcinoma, metastatic
Lymphoma

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H. Supporting Investigation

1) On palpation palpable clear boundaries, bernodul one or more, chewy consistency.

2) Human thyrologlobulin (for thyroid malignancy)
3) In laboratory tests, it was found serum T4 (troksin) and T3 (triyodotironin) within normal
limits. The normal value T3 = 0.6 to 2.0, T4 = 4.6 to 11
4) On ultrasound (ultrasound) can be divided solid or not nodules.
5) The certainty of histology can be enforced through a fine needle aspiration biopsy could
only be done by an experienced expert
6) Examination of thyroid fingerprints.
Results can be distinguished three types:
a) cold nodules when catching iodine nil or less than the surroundings. This indicates a low
function.
b) Nodules hot when the arrest of iodine more than the surroundings. This situation shows
that excessive activity.
c) Nodules warm to the arrest of iodine equal to its surroundings. This means that the
function of thyroid nodules together with the other parts

I. Management

1. With the provision of iodized oil capsules, especially for the population in endemic areas
of moderate and severe.
2. Education
The program is aimed at changing people's behavior in terms of diet and promote the
consumption of iodized salt.
3. Injecting lipidol
Lipidol injection target is people living in endemic areas are given an injection of 40% every
three years with doses for adults and children over six years of 1 cc, was less than six years
were given a 0.2 cc - 0.8 cc.
4. Surgery (strumektomi)
At non toxic struma nodosa great to do surgery if the treatment is not successful, there is
disruption for instance: an emphasis on the surrounding organs, indications, cosmetics,
indicative of malignancy that would have suspected.

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5. L-thyroxine for 4-5 months
This preparation is given if there is a warm nodules and thyroid ulng fingerprint examination.
If nodules smaller, dianjutkan therapy did not shrink even when enlarged biopsy or surgery.
6. Fine-needle aspiration biopsy
Carried on until nodules thyroid cyst less than 10mm

J. Complications

1. Impaired swallowing or breathing

2. Disturbances of heart rhythm disturbances in the form of up pnyakit congestive heart (the
heart can not pump blood throughout the body)
3. Osteoporosis, there is increased bone resorption process so that bones become fragile,
brittle and easily broken.

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