A 38 YEARS OLD WOMEN WITH THYROID TUMOR SUSPECTED

BENIGN DD STRUMA NODUSA NON TOXIC DD THYROIDITIS

By:
M Yusuf Brilliant P
G991905036

Supervisor:
Dr. dr. KristantoYuliYarsa, Sp. B (K) Onk.

DEPARTMENT OF SURGERY
FACULTY OF MEDICINE UNS/ RSUD DR. MOEWARDI
SURAKARTA
2019
 Medical Record
History Taking

1. Patient Identity
Name : Mrs.S
Age : 38 years old
Sex : Female
Ethnicity : Asians
Religion : Islam
Address : Karanganyar
Job : Employee
Date of hospitalized : 26 October 2019
Date of examination : 27 October 2019
Medical Record Number : 0147xxxx

2. Chief Complain
Lump on the front neck

3. Present Illness
Patient came to Moewardi Hospital presented with lump in the
front neck. The lump appear at the lefet lateral part of the neck which
sized around ping pong ball since two years ago. Redness and pain at
the site of the lump when it appear are denied. The enlargement of the
first lump two years ago comparing to present time is denied. Difficulty
to breath, swallowing, and speaking are denied.
Complains comprising with pounding heartbeat, sweating, heat
intolerance, unexplained anxiety, increasing appetite, increasing
defecation frequency and unexplained weight loss when the lump
appear are denied. Complains comprising with cold intolerance,
decreasing appetite constipation, forgetfulness, unexplained depression
and unexplained weight gain are denied.
 Patient urinate 3-5x a day which volume aroud 500 ml/urinate.
Urine was clear yellow and there were no sand and blood in the urine. .
Sore and hot feeling when urinate is denied. Patient defecate 1-2x a day
with soft consistency and brown color, blood and mucus are denied.
Hypertension, diabetes mellitus, and allergic are all denied.

4. Past Illness History

History of tumor at the : denied

other part of body (other
than neck)
History of Trauma : denied
History of hospitalization : denied

5. Family’s Illness History

History of same illness : denied
History of allergic : denied
History of hypertension : denied
History of diabetes mellitus : denied
History of heart disease : denied
History of tumor in the neck : denied
History of tumor at the other part of body : denied
(other than neck)

6. Economic and Social History

The patient is a private employee. The patient is curently in Moewardi
Hospital with National Health Insurance Class II.

7. House and Neighbourhood Enviroment

Patient lives in a highland area.
8. History of Nutrition
Patient usually eats 3x/day which menu mostly comprising with
veggies, tempeh, tofu, sometime meat.

9. History of Habitual
Smoking : denied
Alcohol consumption : denied
Regular exercise : denied
Chemical using : denied
B. PHYSICAL EXAMINATION
I. General Circumstance
1. General circumstance : Composmentis GCS E4V5M6.
2. Vital sign :
Blood pressure : 130/80 mmHg
Heart rate : 80x/minute, ritmic
Respiration rate : 20x/minute
Temperature : 36,50 C

II. General Survey

1. Skin : icterus (-), dry (-)
2. Head : other lump (-), ulcer (-), inflammation (-), facial
nerve paralysis (-/-)
3. Eyes : anemic conjunctiva (+/+), exophthalmos (-/-), lid
lag(-/-), lid retraction (-/-), scleral icterus (-/-).
4. Nose : Symmetric, inflammation (-/-), secretions (-/-).
5. Ears : Normotia, lump (-), inflammation (-/-),
6. Mouth : wet mucosa (+), cyanosis (-).
7. Neck : See Localized Status
8. Cor
I: ictus cordis not visible
P: ictus cordis not strong lift
P: the heart border impression is not widen
A: heart sound I-II normal intensity, regular, noisy (-)
9. Pulmo
I: symmetrical chest development (+), retraction (-)
P: fremitus right = left
P: sonor/sonor
A: vesicular base sound (+/+), additional sound (-/-)
 10. Abdomen
I: abdominal wall parallel to the chest wall, distension (-)
A: bowel sound (+) normal
P: tympanic
P: tenderness (-), pain (-), mass (-)
11. Extremity: CRT < 2 seconds
Oedema Wet Hands Hot hands

- -
- - - -
- -

Fine Finger Tremor

- -

III. Localized Status

Neck Region
a. Thyroid Gland
Inspection:
Seen one nodule at the left lateral part anterior part of the neck.
The nodule appear 2 years ago. The size as big as ping pong ball
with well-define border, redness (-), abcess (-)
Palpation :
Palpabe nodule in the left lateral part of anterior neck which round
in shape and size about 3x4x3 cm, well-defined border, hard in
consistency, firm (+), pain (-), warm in palpation (-), abcess (-),
palpably lower pole in sitting position (-), follow swallowing
movements (+)
Auscultation : Thyroid bruit (-/-)
 b. Lymh Nodes :
Inspection : No visible local lymph node enlargement
Palpation : no palpable lymph nodes enlargement around

c. Jugular Venous Pressure : R+ 2 cmH2O

III. Assessment I
Diagnosis: Benigna Neoplasm of Thyroid Gland (D.34)
Differential Diagnosis:
1. Non-toxic Goiter, unspecified (E04.9)
2. Thyroiditis, unspecified (E06.9)

IV. Plan I
a. Clinical laboratory testing
b. Thyroid : TSH, T3, T4
Then Radionuclide thyroid scan (if TSH abnormal)
c. Thyroid ultrasound and neck lymph node screening
d. Fluorodeoxyglucose - Positron Emission Tomography (FDG-
PET) Scan and Fine Needle Aspiration Biopsy (FNAB) because
nodules are larger than 1 cm. The FNA results are reported using
the Bethesda System
V. Attachment