Clinical case presentation

By - Dr SOMANATH
• Name : Gajarabai
• Age : 43 years
• Sex : female
• Occupation :labourer / house wife
• Address : Bagadari ,TQ: Basavakalyan dt: Bidar
• Socioeconomic status :Lower middle class
• Chief complaints :swelling infront of neck since 2yrs
• History of presenting illness :
Patient was apparently well 2yrs back when her family member
noticed a swelling in front of the lower part of neck insidious in onset
initially of small size around 2cm then gradually progressed to attain the
present size of around 5cm.
• No h/o rapid increase in the size
• No h/o pain over the swelling
• No h/o difficulty in swallowing /dyspnea/change in voice
• No h/o other swelling in the neck
• No h/o suggestive of hypothyroidism (like weight gain inspite of poor
appetite ,constipation, intolerance to cold weather and preference to
warm climate, dry skin , loss of hair ,dull expression etc)
• No h/o suggestive of hyperthyroidism (like loss of weight inspite of
good appetite, preference to cold and intolerance to heat, excessive
sweating , irritability ,insomnia etc)
• No h/o cough , bony pain, hemoptysis
• No h/o radiation exposure
• Not a diabetic or hypertensive

• Past history:
• Not a known case of tuberculosis
• No h/o any surgery or procedure in the past
• Family history:
No h/o similar complaints or thyroid cancer in the family members.

• Menstrual cycle history:

• Regular menstrual cycles 4/28days cycles
• Patient P2L2

• Personal history:
• Diet : mixed (h/o consumption of brassica family vegetables )
• Sleep: sound
• Appite : normal
• Bowel and bladder : regular and normal
• No h/o smoking / alcohol consumption
• Drug history : no h/o any drug intake
Examination :
• General physical examination :
• Patient was examined in well lit room with the informed consent in a sitting
position in the presence of female attender .
• Patient was cooperative , well oriented to time , person and place.
• Moderately built and nourished
• BMI :22.1 kg/m2
• Karnofsky performance scale :90
• Vitals:
• PR :94bpm , regular rhythm , good volume and character.
• BP :118/70 mmhg
• Spo2 :98% under room air
• Temperature : afebrile
• Hair – normal in colour and texture
• Eyes - No pallor ,No icterus
- No lid lag, exophthalmos, no difficulty in convergence
• Face –No puffiness
-No cyanosis
• No lymphadenopathy
• Hands -No tremors
- No clubbing
- No excessive sweating
-No cyanosis
• ENT examination : normal
• No tremors or fasciculation of tongue
• Feet –No edema, No cyanosis
• No bony tenderness or bony swelling
• Proximal myopathy absent
Examination of Neck
• Inspection :
• Examined the patient in sitting position ,me infront at the same level.
• A globular swelling of size 6*5cm (vertical and horizontal dimentioins
respectively) is seen in front lower part of the neck .confined to the right side .
• Lower border of swelling is visible .
• Swelling moves up with deglutation .
• Swelling doesn’t moves up with protrusion of tongue.
• Skin over the swelling appers normal .
• No dilated veins noted over the neck and upper chest.
• No scar or sinuses
• No other swelling were noted in the neck.
• Trachea appers to be in the centre.
• Palpation :
• No local raise of temperature.
• Non tender.
• A swelling of size 6*5cm present in the right side of lower part of neck.
• Extent of the swelling from midline to anterior border of right SCM.
Above upto thyroid cartilage, below upto 1cm above the right
sternoclavicular joint.
• Smooth surface .
• Well defined borders with palpable lower border.
• Uniformly firm in consistency .
• Swelling moves in both direction along with trachea. Not fixed to overlying skin or underlying
structure.
• No pulsation or thrill palpable.
• Rest of the thyroid gland is not palpable.
• Trachea is in the midline .
• Bilateral carotid artery pulsation palpable at normal position.
• Kocher’s test : negative
• No cervical lymphnode palpable

• Auscultation :
• No bruit heard

• Systemic examination
• CVS: S1 S2 heard , no murmur
• CNS: conscious , oriented. HMF- normal
• RS: B/L air entry present , no added sounds
• PA: soft , no organomegaly , bowel sounds heard.
Summary
• 32yr old lady with gradually progressive swelling in the lower part of
neck region for 2yrs without any pressure symptoms or associated
pain with no history suggestive of hypo or hyperthyroidism without
any significant family history
• Single firm globular swelling of size 6*5cm in front in the right side of
lower part of neck region moving with deglutaion . Rest of thyroid
gland is not palpable without cervical lymphadenopathy with no
evidence of retrosternal extension.
Provisional diagnosis:
• Non toxic solitary thyroid nodule of right lobe of thyroid probably
benign etiology.
DDs
• Colloid nodule
• Follicular adenoma
• Thyroid malignancy
• Thyroid cyst
• Toxic solitary thyroid nodule