Case presentation
Venkatesh G
Thanga Rajeshwari K
Mrs Prema 35 year old female from Tharuvai who is a
homemaker came with chief complaints of
Swelling in front of neck for past 6 years
History of presenting illness
• The patient was apparently normal 6 years back suddenly
she noticed a swelling in front of neck which was insidious in
onset , slowly progressed to present size
• 3 years later the patient started developing,
• History of palpitation.
• History of breathlessness during exertion
• History of heat intolerance and excessive sweating
• History of loss of weight inspite of good appetite
• No History of tremors, irritability and sleep disturbance
• No history of double vision
• No history of difficulty in swallowing and hoarsenesss of
voice
• No history of cough with hemoptysis, bony pain
• She went to Tenkasi GH and started on medication for
hyperthyroidism
• Now the patient was referred to TVMCH for further
treatment
Past history
• The patient had no similar complaints in the past
• The patient is not a known case of diabetes mellitus,
hypertension, tuberculosis,bronchial asthma and epilepsy.
• No history of previous radiation exposure
• No history of previous thyroid surgery
Personal history
• The patient consumes mixed diet.
• She is not an alcoholic or smoker
• Regular bowel and bladder habits
• Normal sleep pattern
Menstrual history
• Patient attained menarche at 13 yrs .
• Regular 3/30 days cycle with moderate flow not associated with
pain and passage of clots
Treatment history
• Patient on Tab. Carbimazole for past 3 yrs
• Takes tablet regularly and on monthly follow-up in Tenkasi
GH
Family history
• No history of thyroid disorders among family members
present.
Summary
A 35 years old female Mrs Prema came with complaints of
swelling in front of the neck for past 6 years with history of
breathlessness on exertion, palpitation , weight loss, heat
intolerance 3 years back and started on tablet carbimazole.
General examination
• The patient is conscious , oriented,
• Moderately built and nourished
• No pallor/cyanosis/icterus/clubbing/pedal
edema/generalized lymphadenopathy
• No tremors present
• No eye signs
• Skin and oral cavity normal
Vitals
• Pulse rate: 75/min, regular rhythm, normal volume, no
specific character, no vessel wall thickening, no radio femoral
delay, felt equally on all peripheries
• Blood pressure: 120/80 mm Hg measured at right arm in
sitting position
• Respiratory rate: 18/min
• Temperature: 98.4 F
Local examination
Inspection
After getting consent from the patient ,the patient is exposed
upto nipples with neck extended examined in sitting position
with myself standing infront of the patient
• A butterfly shaped swelling of size 10*7cm in front of the neck
in thyroid region
• Extending superiorly 8cm below the mandible , inferiorly 4cm
above suprasternal notch, laterally upto anterior border of
sternocleidomastoid muscle on both sides
• The surface appears nodular with well defined margin
• Skin over the swelling normal, no scars, sinuses and dilated
veins.
• The swelling moves up with deglutition ,lower border of
swelling visible.
• Trachea appears to be in midline
Palpation
• Inspectory findings are confirmed
• No warmth or tenderness over the swelling
• A nodule of size 3*2 cm on right lobe and a nodule of size
2*2 cm on isthumus is palpable Surface nodular firm in
consistency, plane deep to deep fascia
• Lower border is palpable on deglutition
• Carotid pulsation felt equally on both sides
• Trachea is in midline , Kocher’s test negative
• No thrill felt
• No palpable cervical lymph node
Auscultation
• No bruit heard over the swelling
Examination of other system
• CVS: S1 S2 heard, no murmur
• RS: normal vesicular breath sounds heard
• Abdomen: soft, non tender, no organomegaly
• CNS: no focal neurological deficit
Diagnosis
A case of toxic multi nodular goitre with no features
suggestive of malignancy
Investigations
Routine investigations
• Complete blood count
• Coagulation profile
• Blood grouping and typing
• Urine- albumin, sugar, deposit
• Chest X ray
• ECG
• X ray neck AP / lateral view
• Sleeping pulse rate
• USG neck
• Thyroid function test
• USG guided FNAC
• Radio iodine uptake study
• Thyroid antibodies
• Indirect laryngoscopy
Treatment
Total thyroidectomy with thyroxine replacement
Thank you
