Surgery clinical case

presentation
-Riddhi Soni
-Final year M.B.B.S student
DEMOGRAPHIC DATA:
• Name: Mrs.XYZ
• Age: 35yrs
• Occupation: Housewife
• Residence:Alibaug
• Date of admission: 10/10/21
CHIEF COMPLAIN:
• Swelling in the front lower part of the neck since 2 years.
HISTORY OF PRESENTING ILLNESS:
• The patient was apparently alright 2 years back when she suddenly
noticed a swelling in the front lower part of the neck. The swelling
was small to start with and gradually increasing in size. She
experienced a loss of appetite and weight loss, anxiety and
palpitations.
 NEGATIVE HISTORY:
• No h/o pain
• No h/o fever
• No h/o dsynea, dysphagia, hoarseness of voice
• No h/o of recurrent fainting attacks
• No h/o weakness, lethargy, swelling of face or body , intolerance to
cold, dry skin, menorrhagia and constipation
• No h/o intolerance to heat, diarrhoea or oligomenorrhea
• No h/o irritability on slight provocation
• No h/o insomnia
NEGATIVE HISTORY:
• No h/o any drug intake
• No h/o similar swelling on the lateral side
• No h/o bone pain or any swelling in the spine of the flat bones
PERSONAL HISTORY :
• Appetite: Reduced
• Diet :Mixed
• Bowel and Bladder: Regular
• Sleep: Normal
• Addiction: Denies any addiction
MENSTRUAL HISTORY:
• Regular monthly cycles
• 29 days between to cycles
• It lasts for 4 days
• Change of 3 pads in a day.
FAMILY HISTORY:
• No similar history in the family before.
• No similar history in the neighbourhood.
PAST HISTORY :
• No h/o of asthma, tuberculosis, hypertension or diabetes mellitus
• No h/o radiation exposure in the neck, head and chest.
SUMMARY:
• A 35 year old female comes with a complain of swelling over the front
side of neck since 2 years my probable diagnosis of the case is a
solitary colloid goiter.
GENERAL EXAMINATION:
The patient was conscious, cooperative and well oriented to time, place and
person.
VITALS:
• Pulse: 93 bpm, regular rhythm, normal volume ,force and tension. No
radio-radial delay or radio femoral delay. All peripheral pulses felt
bilaterally.{ Sleeping pulse is taken}. Not a collapsing type of pulse.
• Blood pressure:110/70 mm of mercury in right arm in supine position.
• Respiratory rate : 22 cycles/min.
• Temperature : 96.6 F (measured in the axilla)
• Built:lean
• Skin : Not moist or dry.

• Pallor: Absent
• Icterus: Absent
• Clubbing: Absent
• Cyanosis: Absent
• Lymphadenopathy: Absent
• Edema: Absent
LOCAL EXAMINATION:
The patient was examined with due consent under adequate illumination and in the presence of a female attendant.
She was exposed till the sternum

INSPECTION:
• A single swelling which is 8*10 cm and spherical which is present in the lower part in the
front and extending to the sides upto the sternomastoid, below till the thyroid cartilage
and upto the suprasternal notch.
• Surface:smooth
• Margins:well defined
• Lower border of swelling is well defined and visible
• Skin over the swelling appears normal
• No visible pulsations
• Swelling movement with deglutition is visible
INSPECTION:
• Swelling movement with deglutition is visible
• Upward movement of swelling with protrusion of tongue is absent
• Trails sign: Sternal head of the sternocleidomastoid muscle is not
prominent
• No other visible swelling.
 PALPATION:
The swelling is palpated by standing behind the patient by the classical method

• No local rise of temperature

• No tenderness
• All my inspector findings are confirmed.
• Size: 8*10 cm
• Shape: spherical
• Surface: smooth
• Margin: well defined
• Consistency: firm
 PALPATION:
• Mobility :present
• Moves with deglutition
• Non pulsatile swelling
• No thrill
• Mobility from side to side present
• No tracheal deviation {three finger test}
• Kochers sign: negative
• Berrys sign: negative {carotid pulsations felt at the anterior border of the
sternocleidomastoid at the level of the upper border of the thyroid
cartilage}
PERCUSSION:

• Superior mediasternum :resonant

AUSCULTATION:

• Done on the upper pole of thyroid: No bruit heard.

EXAMINATION OF THE CERVICAL LYMPH NODES:

• No cervical lymphadenopathy
 EXAMINATION OF TOXIC SIGNS:
• Tremor: fine tremors present in the hand.
• No bruit heard in the upper pole
• Eye signs:
1. Joffroys sign: loss of wrinkling of forehead present thus positive
2. No exophthalmos
3. Dalrymples sign: upper scelra not visible
4. Von grafes sign : negative
5. Mobius sign: negative
6. Stellwag sign: negative
SYSTEMIC EXAMINATION:
1- Cardiovascular system :
• S1 and S2 heard
• No murmurs heard

2- Respiratory system :
• Normal vesicular breath sounds heard
• No added sounds

3-Centravl nervous system:

• Higher mental functions normal
• No lethargy or anxiousness
 PROBABLE DIANGOSIS:
30 year old female a case of solitary colloid goiter in hyperthyroid state
with a sporadic etiology without complication and any retrosternal
extention .
THANK YOU.