Faculty of Medicine and Health Sciences

Score sheet for CASE Write-Up

General Surgery & Anesthesia (UMCC 3068)

Year 3 MBBS

Student Name: Khoo Er Hau

ID No: 16UMB05703 Year: 3

Name of lecturer: Dr. Saw Min Oo

Marks allocation of case write-up

Presenting complaints (PC) /5 Discussion of diagnosis and /15

differential diagnoses

History taking: /20 Management and Follow Up /10

Chronologically clear with relevant
positive & negative findings

Physical examination findings: /20 Discussion on patient safety and /3

Clearly and succinctly documented professionalism if relevant

Summary of case: /10 Discussion on communication and /3

Clear and concise ethics issues if relevant
Investigations: /10 Proper use of English language, /4
State indications, test results and and case write-up is clear &
their interpretations logical

Total score /100

Lecturer’s Signature

___________________
 PATIENT IDENTIFICATION

Patient’s Initial: Ms. W Hospital/Card Number: AM00531945

Gender: Female Date of Admission: 16/2/2019
Age: 71 Date of Clerking: 17/2/2019
Nationality: Malaysian Date of Discharge: 21/2/2019
Ethnic Group: Chinese Source of History: Patient

CLINICAL CASE
Presenting Complaints:
Ms. W, a 71-year old Chinese lady presents to the hospital with a swelling on the right side of
the front of the neck for 11 months

History of Present Illness

Ms. W was in her usual state of health until 11 months ago where she noticed a
swelling on the right side of front of her neck, near the base and midline of the neck. The
neck swelling originally was a 20-cents coin size, however the swelling progressively
enlarged, and within 3 months it became a ping-pong ball size swelling. According to Ms. W,
the swelling was painless, round in shape, immobile and firm to touch. There was no
overlying skin changes or discharge from the swelling. She has not experienced any neck
pain, voice change, hoarseness of voice, respiratory complaints, painful swallowing, globus
sensation or otalgia.
However, for the past 8 months prior to current admission, she has experienced
minimal weight loss (around 3 kg) and loss of appetite. Apart from that, she had also
complaint of restlessness and trouble sleeping. All of these complaints she claimed was
attributed to the constant stress of having a visible and palpable neck swelling and where her
request for surgical removal was turned done multiple times.
Otherwise, she had denied any heat or cold intolerance, lethargy, palpitations, muscle
weakness, tremors or constitutional symptoms such as fever and night sweats. She also
denied chest pain or any history of passing loose stools. Physically she also did not notice any
bulging eyes, facial puffiness, swelling of the leg or eyelids.
After multiple visits to the Klink Kesihatan Ampang, she was referred to Hospital
Ampang for a series of investigations and currently admitted to the ward for surgical
intervention.
Systemic Review
No chest pain, no palpitations, no history of syncope, no prior exertional
Cardiovascular
dyspnoea, orthopnoea or PND, no oedema
No dyspnea, no constant cough, no stridor, no haemoptysis, no
Respiratory
rhinorrhoea, no wheezing, no voice hoarseness
No abdominal pain, no dysphagia, no nausea or vomiting, no change in
Gastrointestinal
bowel habit, no change in stool colour
No dysuria, no sudden increase in frequency, no nocturia, no haematuria,
Genitourinary
no urinary incontinence, no urethral or vaginal discharge
No headache, no weakness, no hearing or visual abnormalities, no
Neurological memory or concentration problems, no altered cognition or loss of
consciousness, not easily agitated or irritable
Endocrine No heat or cold intolerance, no excessive thirst, no excessive sweating
No sore throat, no eye symptoms (redness, discharge, excessive tearing,
HEENT
diplopia), no ear discharge
Musculoskeletal Only occasional leg pain ever since age 55 from aging process, no tremors
No sudden hair loss, no dry skin, brittle nails, no skin changes or abnormal
Skin
pigmentation
Psychological No depression or easy mood swings, no anxiety
Others No rash, no bleeding tendencies,

She has not had any abnormalities during her menstruation period (no menorrhagia or
dysmenorrhea) and she had attained menopause at the age of 55 years old.

From the systemic review, Ms. W does not have any acute complaints related to
hyper/hypothyroidism status nor or other non-associated conditions.

Past Medical & Surgical History

More than 20 years ago, she has had a history of symptomatic cholelithiasis with
laparoscopic cholecystectomy done. Subsequently on year 2005, she had a cataract removal
surgery done under local anesthesia. Both surgical operations were successful with no
postoperative complications.
 During 2011 (at age 63) when she suffered a sudden episode of hypertensive crisis,
she was diagnosed with severe hypertension. Currently she is on Amlodipine 10mg once
daily and Perindopril 2mg once daily, and she is compliant to the medication thus far.
Although, she does not regularly monitor her blood pressure and only occasionally does so
when she visits KK for every 3-monthly checkup, according to Ms. W her average blood
pressure is on a declining trend, currently systolic ranging within normal limits around 110-
130mmHg, and diastolic ranging around 75-90mmHg.
2 years ago, she suffered from itchy patches over bilateral legs and feet, and later was
diagnosed with eczema. Her current treatment consists of topical application of Glycerine
25% + Aqeous cream (100gm) applied thrice daily and Bethamethasone cream (100g)
applied once daily. Her current dermatological condition is under follow up in Hospital
Ampang Dermatology Department.
Otherwise, there were no other medical history of note such as diabetes or
hypercholesterolemia. No previous history of thyroid diseases or malignancy. He had not
undergone any head or neck surgery. There were no previous history of head or neck
irradiation.

Drug History & Allergy History

Apart from the antihypertensive medications and topical regimen for her eczema
(mentioned above), she is currently not on any other long-term medication. There was no
history of taking any iodine-containing drugs, antithyroid medication or thyroid supplements.
She also did not take any traditional medicine or recreational drugs. She denied any drug,
food or environmental allergy.

Family History
Her mother has a history of malignant breast cancer diagnosed at the age of 60 and
passed away at the age of 68. Apart from that, her father and siblings are all alive and well.
There are no family members with similar complaints of neck swelling previously. There are
no family history of benign or malignant thyroid diseases, no related family history of
hereditary endocrine disorders as well.
Social History
Ms. W is currently retired, previously worked as an administrative clerk for 36 years.
She has no occupational exposure towards radiation. She’s ADL independent, currently not
married, has a stable income and staying in a condo house in Ampang Jaya alone. She has no
history of tobacco use, alcohol intakes or illicit drug abuse. No history of high-risk behavior
as well. She currently exercises, jogs and meet friends on a daily basis to stay healthy.
Although recently due to the psychological stress pertaining to her neck swelling, where she
has been having loss of appetite and eats mostly liquid based food only (porridge, oats, soup),
prior to this, she practices a normal and balance diet. There was no history of excessive intake
of goitrogenic food (cabbage, brussel sprouts, kale, cauliflower), taking too little or too much
iodine-containing food (fish, seaweed etc.)

Ideas, Expectations, Concerns

Ms. W is only currently concerned with removing the neck swelling. According to
her, the fear of not having surgical intervention on her neck swelling is greater than the fear
of the neck swelling being a malignant cause, as she explained “it is not comfortable living
daily knowing you have lump in the neck”. For her, she also strongly believes that her current
predicament, where she could not sleep and could not eat was because of the psychological
stress from the neck swelling itself, as the symptoms occurred only after discovery of the
swelling and ceased when she was informed that surgery could be done for her.
 PHYSICAL EXAMINATION
The temperature was 36.7°C, she is afebrile to touch. Respirations 21 breaths per
minute but patient does not look tachypneic. No nasal flaring, pursed lip breathing or prominent
accessary muscle breathing noted. The blood pressure was 133/62 mm Hg on the left arm, and
135/62 on the right arm. The oxygen saturation was 96 percent while the patient was breathing
ambient air. Patient has a height of 161cm with a weight of 57kg (BMI kg/m2).
On physical examination, the patient was conscious, alert and oriented, and looks
comfortable at rest. Glasgow coma scale (GCS) is full. She looks pink but with no signs of
jaundice or pallor. There are no abnormal facies. A branula was in situ on the right dorsum of
the hand, functioning well with no extravasation or thrombophlebitis. Patient is wearing
compression stockings. She is able to speak in full sentences with no stridor or hoarseness of
voice.
On general examination, there is no puffy face or obvious muscle wasting. She has a
well built with no signs of jaundice or anemia (no conjunctival pallor or scleral icterus).
Examination of head shows no alopecia.
On examination of the hands, both hands felt normal in temperature with minimal
sweating. There was no thyroid acropachy, onycholysis or other abnormal nail changes. There
was no fine tremor or palmar erythema. Good skin turgor is appreciated and both hands does
not seem dry. The radial pulse 71 measured at beats per minute with regular rhythm and good
volume. There are no bounding or collapsing character. Capillary refill time was less than 2
seconds and there is no peripheral cyanosis. Examination of lower limbs shows no edema,
thyroid dermopathy (pretibial myxedema). varicose veins
On examination of the eyes, there is xanthelasma noted around the lower border of the
right eyelid. There is no loss of lateral third of the eyebrows or puffiness around the eyes. There
is no thyroid eye stare or infrequent blinking (Stellwag’s sign). There is no increased
pigmentation of superior eyelid folds. The superior limbus of the eyes and upper sclera are not
visible in normal position, and both eyelids are on the same level, there is no lid retraction.
There is no exophthalmos from the front as well as using Naffziger’s method.
Both upper eyelids are able to keep pace with eyeball, no lid lag is seen on infraduction
(Von Graefe’s sign) or supraduction (Kocher’s sign). There is no absence of wrinkling of
forehead folds when Ms. W looks up with head bent forward (Joffroy’s sign). Examination of
conjunctiva reveals no chemosis, conjunctival injection or pallor. There is also no visible
corneal ulceration.
 Further examination of eyes show extraocular movements were all coordinated with no
diplopia, there is no ophthalmoplegia. Accommodation reflex is intact with both eyes able to
converge (absence of Mobius sign). No signs of Horner syndrome (ptosis, anhidrosis, miosis)
seen as well.

Neck Examination
On first glance, the neck looks asymmetry with deviation of the midline of the neck.
There is a single visible large localised swelling over the anterior triangle of the right side of
the base of the neck, that moves upwards with deglutition measuring around 4cm x 5cm,
however it does not move with tongue protrusion and is hemispherical in shape. The lower
border of the swelling could be clearly seen when the swelling move upwards during
deglutition. The anterior jugular vein is prominent (possibly pressure effect) and there are no
overlying skin changes, no visible pulsation or surgical scars. There are no grossly enlarged
lymph nodes.
On palpation, there was no local rise in temperature over the swelling. Through
swallowing and Lahey’s method, the neck swelling on the right anterior triangle is confirmed
to be confined to the thyroid. The size of swelling measures similar to that approximated from
inspection. The swelling is oval in shape, has a smooth but nodular surface, firm consistency,
with a well-defined margin and regular outline. There is no skin attachment and no tenderness
elicited. The swelling is mobile in the up-down direction however restricted from side-to-side.
Upon swallowing, the lower border of the swelling can be palpated, with no dilatation of
subcutaneous veins on upper anterior thorax (no retrosternal extension).
For the left thyroid lobe, the thyroid surface is irregular as 1-2 small smooth-surfaced
satellite nodules (less than 1cm) are palpable as well. There are no palpable thrills over the
whole thyroid.
There is also palpable submandibular lymph node on the left side, measuring around
1cm, which is soft in consistency, mobile and non-tender. Other cervical lymph nodes are not
palpable.
Bilateral carotid pulses was unable to felt, Berry’s sign is positive. There is no stridor
on compression of lateral lobes, Kocher’s sign is negative. There is no tracheal deviation and
Pemberton sign is negative.
Percussion over the sternum produces no dullness, hence again confirmed there’s no
retrosternal extension. On auscultation, there are no thyroid bruit over the right thyroid swelling
as well as other parts of the thyroid. No carotid bruit is present.
Neurological examination
For motor examination, inspection and palpation of muscle bulk of all four limbs
revealed no tenderness or atrophy. There’s no tremor, fasciculations or involuntary movements
observed. Tone of all four limbs are normal with no spasticity or rigidity felt. Power was graded
5/5 in bilateral upper and lower limb flexors and extensors. There’s no proximal myopathy on
raising arms above the head and on flexing the hip. The deep-tendon reflexes were ++ for both
left and right biceps, triceps, brachioradialis, knee and ankle.
To complete examination on neurological aspect of the eyes as patient had cataract,
visual acuity was checked and Ms. W has a normal visual field with a visual acuity of 6/9
bilaterally. Both pupils were reactive with no relative afferent pupillary defect. Assessment of
other cranial nerves and cerebellar function was not done as it was not indicated.

Musculoskeletal
On inspection, there are no bone deformities, muscle wasting, or scars. On palpation,
there’s no swelling, tenderness or local rise in temperature in bilateral upper limbs and lower
limbs. Active and passive movement of both arms and legs were full, including that of the
spine.

Chest Examination
The chest is normal in shape, bilaterally symmetrical without undue elevation or
recession, and moves with respiration. There is no deformity, scars, spider naevi or dilated
veins. No prominence of accessory muscles for breathing. There are no precordial bulge. Apex
beat is not seen and not palpable. Chest expansion was normal. No thrills on all 4 areas of the
heart could be felt. There’s no parasternal heave. On percussion, the lungs are resonant on both
front and back of left and right lung. Normal cardiac dullness border was also appreciated. On
auscultation, similar intensity S1 and S2 hearts could be heard at all 5 areas of the heart (mitral,
tricuspid, pulmonic, aortic and Erb’s point) with no additional heart sounds or murmur. Normal
vesicular breath sounds are heard on both sides of the lung with no adventitious breath sounds.
Normal vocal resonance with heard with no bronchophony or egophony.
As patient has family history of breast cancer, examination of breast was done and
showed no gross abnormality, no palpable breast lump or axillary lymphadenopathy.
Abdomen Examination
Upon inspection, the abdomen was flat with no bulging flanks noted. Multiple well-
healed scratch marks are seen all over the central abdomen as well. The abdomen moves with
respiration. Umbilicus is centrally located, inverted, normal with no paraumbilical swelling.
There are no signs of abdominal or inguinal hernia, and no expansile cough impulse are seen
at the hernia orifices, however patient was noted to be in pain when he attempted coughing.
There was no local swelling, abdominal straie, visible peristalsis, aortic pulsations, dilated
veins, fistulas or sinuses over the abdomen.
On palpation, the abdomen is soft, non-tender and there is no guarding, rigidity or mass
felt. The liver and spleen are not palpable, and kidneys were not ballotable. On percussion,
dullness on percussion of upper lobe of the liver is appreciated from the 5th intercostal space
mid clavicular line, bordered by the 7th rib at the mid axillary line and the 9th rib at the
midscapular line. Liver inferior border was percussed near the 10th intercostal space,
measurement of liver span was around 8cm at the midclavicular line (normal liver span). On
percussion across the Traube’s space, it produces a tympanic sound. Shifting dullness was
negative, with no demonstrable fluid wave. On auscultation, there’s normal bowel sound with
no liver or renal bruit. There are no palpable femoral or inguinal lymph nodes. Rectal and
genital examinations are not done since not indicated.

Case Summary
Ms. W, a 71-year old Chinese lady with underlying hypertension and eczema presents
with a painless swelling in the right anterior triangle of her neck during the past 11 months.
She complaints of loss of appetite, restlessness and insomnia following discovery of swelling,
but she has had no compressive / obstructive symptoms. She has no personal history of
thyroid disease, radiation exposure, and no family history of thyroid disorders.

On physical examination, apart from respiratory rate of 21 breaths per minute, other
vitals are normal. She has 4cm x5cm swelling over the anterior triangle of the right side of
the base of the neck that moves superiorly with deglutition with multiple tiny nodules over
the left thyroid lobe. There is no tenderness, tethering to skin, no retrosternal extension, no
tracheal deviation and no cervical lymphadenopathy, however Berry’s sign is positive. The
patient’s palm appears slightly diaphoretic, but other physical examination is normal
otherwise, with no signs of thyroid dysfunction.
Differential Diagnoses
The differential diagnoses can be approached from the standpoint that patient’s neck
swelling is most likely thyroid in origin, as framed from two critical pieces of information –
neck swelling moves with deglutition, and neck swelling is confined to the butterfly-shaped
structure below the cricothyroid cartilage. Given the nature of the patient’s presentation, the
differential diagnoses is framed based on the single solitary nodule in the right thyroid lobe
present with certain consideration for the multiple small nodules present on the left thyroid
lobe.

Provisional diagnosis
Right dominant nodule in a multinodular goiter
To quote Norman Browse in his excerpt on solitary thyroid nodule “although only one
nodule may be palpable, one-half of the patients who present with a solitary nodule actually
have a multinodular goiter, i.e. a clinically dominant nodule in a macroscopically multinodular
goiter”. Multinodular goitre occasionally can clinically present as solitary nodule but
microscopic changes will be present throughout the gland.
The fact that on physical examination, the nodular surface of the right neck swelling
which has a smooth texture could be palpated points patient’s condition towards multinodular
goiter as the most likely diagnosis. A small number of nodules could also be palpated on the
left side (multiple areas of nodularity) apart from the large swelling of the right thyroid lobe
\also supports.
There is an old saying that “solid lumps in the thyroid feels cystic, whereas cystic lumps
feels solid”. The explanation is that nodule composed of thyroid tissue is soft, but in this case
where a firm to hard consistency nodule is usually full of blood and liquefied necrotic tissue
that makes it tense.
By statistics, all types of thyroid nodule are more common in the female than in the
male owing to the presence of oestrogen receptors in the thyroid tissue, in fact studies have
shown that they are 4-6 times more common. As our patient here is 71 years old, the risk for
multinodular goiter also increases exponentially. Although most multinodular goiter have been
postulated to be due to iodine deficiency (endemic goiter), but taking into account of Ms. W’s
age and Ms. W’s living address, we cannot rule this out as sporadic goiter can occur as well
(commonly presenting much later in life such as in this case), as genetics play a huge role in
this influence with the following genes responsible - MNG-1 (multinodular goiter-1) gene,
DICER1 mutations.
 Especially in this patient where she is mostly asymptomatic apart from the acute
complaints of loss of appetite and insomnia, this is also typical to that multinodular goiter,
whereby the slow natural course of this condition usually presents with no symptoms
(sometimes coincident changes in lifestyles adapts to the chronicity).
On examination, the fact that the swelling is “painless” as well as “mobile” makes this
differential diagnosis more likely, ruling out the more malignant or severe condition. The lump
moves upwards during swallowing, this indicates to us that it is fixed to traches but nearby
structures.
Furthermore, there were no symptoms of invasion such as dysphonia, dyspnea,
hemoptysis, stridor or dysphagia, no bruit heard on auscultation, and no sudden rapid
enlargement of a nodule which can raises suspicion of carcinoma. Although Berry’s sign was
positive, this could be due to the engulfment by the large neck swelling (not due to the displaced
of the carotid pulse) or the compression of carotid artery by the dominant nodule of
multinodular goitre.
Further physical examination also shows that there is no thyroid dysfunction (no eye
signs, no proximal myopathy, no vital or pulse abnormality etc.) in Ms. W, this tells us that
patient is most likely clinically euthyroid. This is again, although not absolute, but common
among those who have multinodular goiter with just one dominant nodule, as toxicity usually
manifests when there are presence of >2 autonomously functioning thyroid nodule that secretes
excess thyroid hormone (in the case of toxic multinodular goiter).
Finally, as patient has had no personal or family history of benign or malignant thyroid
disease, no history of radiation exposure, no history telltale of goitrogen excess, all this possibly
points towards this relatively benign diagnosis as well.

Differential diagnosis
Carcinoma of the thyroid gland
Carcinoma of the thyroid gland should also be considered in this case due to the
following reasons – age, constitutional symptoms, rate of enlargement. Firstly, when looking
at Ms. W’s age, being at her 70s, the risk of thyroid cancer in a nodule is a lot higher, being
within the extreme ages bracket. According to the medical guidelines for clinical practice for
diagnosis and management of thyroid nodules released by American Association of Clinical
Endocrinologist in 2016, nodules at extremes of age are considered of greater significance (age
< 14 years or > 70 years. Apart from that, although the neoplastic symptoms (loss of weight,
loss of appetite) was claimed by patient to be due to stress, one must consider a multitude of
possibility for which these symptoms may occur, one of which could be attributed to ‘cancer”
apart from hyper/hypothyroidism status or psychological stress. Besides, judging from the rate
at which the neck swelling grew, i.e. progressively during weeks / months which is not slow
like benign hyperplastic nodules and not rapid like hemorrhaging into nodule or the anaplastic
variant of carcinoma, this rapidity of growth very much suggests possible malignancy as well.
Regardless of subtypes of carcinoma of thyroid gland, there’s a risk of malignancy if
this nodule is hypofunctioning (cold nodule) in a case of multinodular goiter. Similarly, as in
multinodular goiter, carcinoma of the thyroid gland when appeared as a solitary nodule can be
spherical, smooth and well defined, and has a nodular surface. Apart from that, there’s a
submandibular lymph node enlarged, neck metastases from thyroid carcinoma should not be
overlooked.
Besides that, thyroid cancers are also more common in female, up to 3-4 times more
than the male counterpart. Although patient does not have any personal or family history of
thyroid malignancy, nor any history of head and neck irradiation, this does not rule out
possibility that we could be dealing with malignancy, the possibility could only be ruled out
through biopsy.
In terms of examination, although patient does not have any obstructive / compressive
signs e.g. recurrent laryngeal nerve palsy, tracheal deviation, SVC obstruction, this also only
tells us that if the thyroid swelling is malignant, the cancer has not infiltrated to surrounding or
large enough to compress nearby vital structures. From the history itself, the absence of
dysphonia, dysphagia, dyspnea, neck pain, symptoms of hyperthyroidism (heat intolerance,
palpitations, anxiousness) or hypothyroidism (weight gain, cold intolerance, apathy) also could
be similarly explained. In order to test out this likely diagnosis, ultrasound could be run prior
to fine needle aspiration biopsy to detect suspicious features suggesting malignancy.
To distinguish the subtypes for differentiation of carcinoma of thyroid follicles, this
could only be confirmed through biopsy. However, by presentation and prevalence, if its
malignant for this patient, papillary thyroid carcinoma is the most likely for this patient, as it
accounts for 80% of all thyroid cancer, especially since taking into account that patient’s age
which is more than 70 years old. Papillary carcinoma lumps like the benign differentials, are
usually non-tender, firm in consistency, not usually fixed to superficial structures, and will
move upon swallowing, very rarely present with retrosternal extension as its not that invasive.
Another type being follicular carcinoma, presents almost quite similarly like papillary
carcinoma, just not as frequently occurring as papillary type. The common abnormality is also
non-tender lump in the neck; usually arising in one of the lateral lobes; appear spherical and
smooth with distinct edges, firm in consistency with normal local tissues; and patients are
usually euthyroid as well.
Anaplastic carcinoma although common between the ages of 60 and 80 years, it is
unlikely due to the fact that patient’s swelling is rather slow growing; not resulting in pain,
hoarseness, otalgia; which is not typical for this variant of carcinoma.
Medullary carcinoma without a significant family history is quite rate, however must
not be left out of the picture as well, The common presentation is also a firm, smooth and
distinct lump in the neck, indistinguishable from any other thyroid solitary nodule. Plus, the
majority of the patients are between the ages of 50-70 years when the tumor is sporadic in
nature. In addition, patient does not have any diarrhea or flushing, which is again very
characteristic in this type of patient.

Right benign thyroid cyst with multiple small left thyroid cyst
Clinically isolated thyroid swelling may be a thyroid cyst which contain fluid as patient
presented with non-progressive painless swelling after a few months, firm consistency, well
defined margin and regular outline without underlying skin changes but the surface of thyroid
swelling is nodular. Thyroid cyst could be firm to hard in consistency because of tense cyst and
occasionally mimic carcinoma. However, some patients develop symptoms, and cystic thyroid
lesions are the most common cause of thyroid pain. As an example, sudden hemorrhage or
hemorrhagic infarction of a solid thyroid nodule can result in a predominantly cystic and
painful neck mass. More extensive hemorrhage may cause hoarseness and vocal cord paralysis
and may compromise the airway, especially if the nodule is located within or below the thoracic
inlet. However, patient did not experience all these symptoms and no pain over these 11
months. So, patient’s thyroid swelling could be a thyroid cyst, however malignancy must be
excluded.

Right thyroid adenoma

Follicular adenomas are the most common type of adenomas and arise from the follicular
epithelium within the thyroid gland. Clinically, follicular adenomas present as solitary nodules
in which this patient presented with, hence making this a likely differential to exclude as well.
In the case of thyroid adenoma, female are more common than male as well. Thyroid adenoma
usually is slow growing and does not metastasise in which in this case, patient presented with
11 months of thyroid swelling which was slowly progressively increasing in size and there
were not symptoms suggestive of malignancy or infiltrations as mentioned in the history. There
were no history of radiation exposure and family history of malignancy as well.

INVESTIGATIONS, RESULTS & INTERPRETATIONS

Upon admission, her blood was collected to perform measurement of thyroid function
to evaluate patient’s thyroid status as a baseline to detect any abnormal function of the
thyroid gland. This is important as apart from diagnosing hyperthyroidism or
hypothyroidism, this thyroid status can at a small extent aid in confirming the cause of the
thyroid swelling. For example, a case of multinodular goiter can have overt or subclinical
hyperthyroidism while thyroid cyst are usually clinical euthyroid unless there are cystic
degenerative changes.

Components Normal range Results Interpretation

Thyroxine, free T4 12.00-22.00 17.48 Normal

(pmol/L)

Thyroid stimulating 0.270-4.200 0.805 Normal

hormone (TSH) (mIU/L)

Thyroid function test done on 5/11/2018

Interpretation: Ms. W’s thyroid function is within normal limits. Regardless of cause, the
thyroid solitary nodule most likely not toxic, and not oversecreting or under-secreting thyroid
hormones.
Although patient’s thyroid function is normal, an ultrasound is still indicated to
confirm the type of nodule we’re dealing with. As patient presents with goiter, ultrasound
must be done to determine the physical characteristics of thyroid swelling and demonstrate
subclinical nodularity and cyst formation, which can also help us to establish risk for
malignancy. Apart from that, neck ultrasonography can also help detect any regional lymph
node enlargement which can confirm if our patient’s submandibular lymph node enlargement
has malignant characteristics. Especially in this case where multinodular goiter is suspected,
this is recommended for all patients with this type of presentation.
Ultrasound done on 6/11/2019
Interpretation: Right thyroid lobe and the isthmus are enlarged. The left thyroid lobe is
normal in size. The right lobe measures 3.9cm x 3.8cm x 4.9cm and left measures 2.7cm x
2.6cm x 4.9cm. Isthmus measures 0.9cm. There are multiple faintly defined hypodense
nodules noted in both the lobes and the isthmus. There is large dominant nodule in the right
lobe measuring 3.6cm x 2.9cm. No retrosternal extension. No cervical lymphadenopathy.
Features are suggestive of multinodular goiter.
As patient presents with history of rapid growth and is of old age, FNA biopsy is done
to rule out malignancy. Thyroid FNA is always recommended to be performed such as in this
case where multinodular goiter is suspected, as cytologic diagnoses were more reliable and
non-diagnostic rates are lower.

FNAC done on 13/11/2018 sent to Cytology Unit , Pathology Department Hospital Serdang
Interpretations: From right thyroid swelling, minimal blood stained fluid is aspirated with
adequate cells seen. Aspirate has a scanty volume, watery texture. Smears show some
monolayered sheets of evenly spaced follicular cells with a honeycomb-like arrangement.
The background is hemorrhagic. Also included are pigment laden macrophages,
inflammatory cells, degenerated material and colloid. FNA biopsy shows a benign lesion
(Bethesda diagnostic category: II)
As patient’s TSH level is normal, there is no ectopic thyroid tissue or retrosternal
goiter suspected from ultrasound and has no history of iodine deficiency, thyroid scintigraphy
(radionuclide scanning using iodine-123 or Tc-99m, it is not indicated. Radionuclide
scanning involving either iodine-123 or Tc-99m is required to determine whether a nodule is
hyperfunctioning and therefore taking up the radiotracer to a greater extent than the
surrounding thyroid gland. It is also less commonly used now to investigate single dominant
nodule that may require further evaluation for malignant potential. As our patient is suspected
most likely to have multinodular goiter and is not toxic, the use of thyroid scintigraphy does
not provide any diagnostic information which alters the way we’ll manage this patient.
Management & Follow Up
Ms. W who presented to Hospital Ampang with a painless thyroid swelling was
scheduled for a series of investigations to diagnose the thyroid nodule. Thyroid function test,
neck ultrasound and FNAC was done. Originally, due to the nature of her thyroid nodule and
her old age, surgical removal was not advocated by the specialists. However, as mentioned
from the psychological stress dawned upon the patient, she was scheduled for a surgical
removal on 18 March 2019. The preferred extent of resection for dominant nodule in this case
of multinodular goiter is ipsilateral hemithyroidectomy (right side).
One day prior to surgery, patient was admitted in for preoperative evaluation and
preparation. With few exceptions, thyroidectomy is elective surgery. Thus, any major
medical issues should be addressed before proceeding to the operating room. Prior to the
operation, a few assessments were done.
1. Vital signs
2. Full blood count
3. Metabolic panel
4. Electrocardiogram
5. Chest-X-ray
6. Thyroid function test
7. Laryngeal examination
8. Serum glucose

1. Vital signs
Pulse rate : 71 bpm
Breathing rate : 16 breaths/min
BP : 123/96 mmHg
SpO2 : 98 % under room temperature and pressure
Temperature : 36.5 °C

Vitals are within normal limits, and patient’s hypertension is under control as seen by
stable blood pressure.
 2. Full blood count (FBC) with differentials
Blood Component Results Reference Range Interpretation
Red Blood Cell count (x10⁶ / μL) 3.97 4.53-5.95 Normal

Haemoglobin (g/dL) 12.2 13.5-17.4 Normal

Haematocrit (%) 38.0 40.1-50.6 Normal
Mean Corpuscular Volume (fL) 95.7 76-98 Normal
Mean Corpuscular Haemoglobin (pg) 30.7 26.9 – 32.3 Normal
Mean Corpuscular Haemoglobin 32.1 31.9 – 35.3 Normal
Concentration (g/dL)
Platelet (K/µL) 198 142-350 Normal
Red Cell Distribution Width CV (%) 13.1 12.0-14.8 Normal
White Blood Cell Count (K/µL) 8.2 4.1 – 11.4 Normal
Neutrophil Count (K/µL) 6.1 3.9-7.1 Normal
Lymphocyte Count (K/µL) 1.2 1.8-4.8 Low
Monocyte Count (K/µL) 0.6 0.4-1.1 Normal
Eosinophil Count (K/µL) 0.3 0 - 0.8 Normal
Basophil Count (K/µL) 0.1 0 – 0.1 Normal
% of Neutrophil 74.0 40-80 Normal
% of Lymphocyte 14.5 20-40 Normal
% of Monocyte 7.7 2-10 Normal
% of Eosinophil 3.2 1-6 Normal
% of Basophil 0.6 <1-2 Normal
Complete blood count done on 17/2/2019
Interpretation:
Red blood cell and their indices, platelet count, total white blood cell count are within
normal range, suggesting patient has no anemia, no underlying platelet abnormality which
can lead to abnormal coagulable state; no underlying infection to worry. Although
lymphocyte count is below normal range of limit, but this should not confer too much worry
as total WBC count is normal. This could be due to undernutrition from poor appetite. On a
safe side, it is not advisable to operate as well if patient has lymphocytopenia as patient
would not have adequate immune system to be surgically fit to fight surgical infections from
bacteria and viruses. Hence, a repeated full blood count should be done to ensure patient’s
lymphocyte count is on par.
 3. Metabolic panel

Subsequently, a complete metabolic panel including blood urea and electrolyte panel was
done as a baseline to screen for any underlying electrolyte imbalance. It is also useful to
monitor the hydration status of the patient. As for serum calcium, upon correction, we can set
an estimation of baseline to monitor for post-thyroidectomy hypocalcemia.
Components Results Reference range Interpretation
Urea (mmol/L) 7.5 2.76- 8.07 Normal
Sodium (mmol/L) 142 136- 146 Normal
Potassium (mmol/L) 3.9 3.4- 4.5 Normal
Chloride (mmol/L) 102 98- 107 Normal
Creatinine (µmol/L) 69 62-106 Normal

Components Results Reference range Interpretation

Calcium (mmol/L) 2.15 2.15-2.50 Normal
Magnesium (mmol/L) 0.93 0.66-1.07 Normal
Phosphate Inorganic (mmol/L) 0.90 0.81-1.45 Normal
Blood urea serum electrolytes and serum creatinine (BUSE, Cr) done on 4/1/2019
Interpretation: As other electrolytes, as well as serum urea and creatinine are normal,
there’s most likely no renal impairment and no underlying electrolyte abnormality.

4. Electrocardiogram
 Interpretations: An electrocardiogram showed a sinus rhythm at a rate of 75 beats
per minute. There’s no axis deviation. No ventricular hypertrophy. No bundle branch
block. No abnormalities seen in P wave, QRS complex and ST segment on other
leads. No pathological Q wave or U wave. No signs of atrial fibrillation or any
arrhythmic changes. No prolonged PR or QT interval. From ECG pattern, this is a
normal ECG with no ischemic changes.

5. Chest X-ray

As a pre-op assessment to minimize intraoperative risk, a chest X-ray was done to rule
out sepsis to the lung or post-appendectomy atelectasis or pneumonia.

Interpretation: This was Ms. W’s chest X-ray done on the 1st day of admission (17/2/2019)
with a posteroanterior erect view. On first glance, patient has prominent bronchovascular
markings, which maybe normal. Airway is central with symmetrical clavicles and no
mediastinal shift. The cardiac size seems normal, however the right heart border are poorly
defined. The costophrenic angle is well demarcated on the right side, but left diaphragmatic
contour is too difficult to visualize for any abnormality. Assessment of any cardiothoracic
abnormality in this case is hard as this is a poor-quality chest x-ray – poorly inspirited (only 5
ribs seen). However, there are no apparent clavicular, rib or scapula fracture. No nodules,
cavities, sclerosis, abnormal masses or calcification seen. No other signs of heart failure e.g.
Kerley B lines, upper lobe pulmonary venous congestion and interstitial oedema. No
pacemaker or central lines seen.

6. Serum glucose (dextrose stick 6.7mmol/L)

Patient’s glucose is considered at the higher end of normal, continuous monitoring to be

advised.
7. Thyroid function test

For all patients undergoing thyroid surgery, a serum thyroid-stimulating hormone (TSH)
level can determine whether the patient is euthyroid, hyperthyroid, or hypothyroid. It is
important patient is euthyroid. If not patient might end up in thyroid storm in post op setting.
Patients with overt hyperthyroidism of any cause who are to undergo surgery should be
treated with an antithyroid drug (ie, methimazole or carbimazole) until they are euthyroid.
Thionamides prevent the thyroid from using iodine as substrate for new hormone synthesis
within two hours after the initial dose. Usually in Malaysian hospital prescribing practice,
carbimazole 30-40mg is given until euthyroid, then the dose is reduced to 5mg 8 hourly.

Components Normal range Results Interpretation

Thyroxine, free T4 12.00-22.00 16.2 Normal

(pmol/L)

Thyroid stimulating 0.270-4.200 0.699 Normal

hormone (TSH) (mIU/L)

Thyroid function test done on 17/2/2019

Interpretation: Patient’s thyroid function is normal

 8. Laryngoscope examination

Prior to operation, patient was referred to ENT for laryngeal examination, Laryngeal
exam is performed prior to thyroid surgery to assess vocal cord function. Preoperative
examination of the vocal cords is most commonly performed by direct or indirect
laryngoscopy. This is to identify any paralysis and for documentation prior to surgery in case
if there’s any injury or trauma to the recurrent laryngeal nerve (RLN) during thyroid surgery
which could result in vocal cord paralysis. Thus, occult RLN paresis and/or vocal cord
paralysis diagnosed preoperatively by laryngeal examination can facilitate operative planning
and patient counseling.
Referral to ENT for vocal cord assessment shows there’s no change in voice, no
shortness of breath, no obstructive symptoms and no recurrent laryngeal nerve symptoms.
Tonsils are not enlarged, patient's Mallampati score (MP) was more than 3 and thyromental
distance (TMD) recorded to 3 finger breaths. Through flexible nasopharyngolaryngoscope,
mobile and symmetrical vocal cords are found. Base of tongue, vallecula and epiglottitis are
normal. Patient’s overall vocal cord assessment is normal
Subsequently, she was briefly explained once again by the surgical team about the
surgical procedures, the possible complications and what are the following management after
the surgery. Ms. W was informed that if histopathological examination of biopsy tissue shows
that nodule is cancerous on either one side of the lobe, patient may have to be subjected to go
for another round of operation. Ms. W understands and agrees. Below are the complications
explained to the patient.
 Bleeding
 Hematoma
 Wound seroma (serous fluid collection)
 Flap necrosis
 Recurrent laryngeal nerve injury (resulting hoarseness of voice which can be permanent)
 Wound infection / Surgical site infection
 Hypocalcemia due to hypoparathyroidism

Subsequently, patient was advised to be nil by mouth. Appropriate supportive care also
included ensuring proper fluids and nutrition preoperatively. Ms. W was also administered with
intravenous fluid (2 pints of normal saline and 2 pints of dextrose 5% over 24 hours). Pre-
anesthetic review (to obtain operation anesthesia consent with risk of general anesthesia
explained & check for allergies) and Group, Screen and Hold (GSH) was done to ensure smooth
operation to account for perioperative anesthesia and intraoperative blood transfusion (if
indicated). Site of operation was also marked. Patient’s antihypertensive medication was
continued.
Thyroid surgery has a very low infection rate because it is a clean procedure performed
in a well-vascularized area. Nevertheless, preoperative antibiotics Cefazolin was administered
within one hour of incision.
Operation Procedure
During op, a continuous bladder drainage was set up for the patient upon administration
of general anesthesia. Patient was placed on the operating table in a supine position with neck
in extension supported by sandbag placed beneath both scapula.
The skin of the anterior neck, from the lower lip/angle of the mandible to the anterior
chest, was prepared. The neck was checked for skin integrity and subsequently povidone iodine
was applied on skin overlying the whole neck.
A Kocher was incision was made sharply on the anterior aspect of the midneck. After
the incision, dissection is carried down to the platysma muscle. Subplatysmal flaps are then
elevated to above the level of the thyroid cartilage superiorly, over the sternocleidomastoid
muscles laterally, and the level of the sternal notch inferiorly. Median raphe between strap
muscles was identified and divided in the midline avascular plane. Deep cervical fascia and
both strap muscles reflected. Middle thyroid vein is identified, ligated and divided first. The
inferior vascular pedicle, along with any other blood vessels going to and from the thyroid in
its vicinity, was ligated, which allows the thyroid lobe to be rolled up and onto the anterior
surface of the trachea
After that, the superior pole of right thyroid gland identified, the superior pole vessels
are ligated close to the gland to avoid injury to the external laryngeal nerve. Right superior
branch of external laryngeal nerve identified and preserved. The inferior pole of right thyroid
gland was identified and ligated as well. Right recurrent laryngeal nerve was identified and
preserved. Right thyroid gland was then dissected. Intraoperatively, a 3 cm x 4cm right thyroid
nodule with surrounding multiple small thyroid nodule was found.
For closure, the surgical field is evaluated for hemostasis and was secured. A size-8
Radivac vacuum drain was inserted into the right thyroid groove and anchored with silk 2.0.
The strap muscles are then reapproximated with absorbable interrupted sutures at the midline.
Median raphe was closed with Vicryl 2/0 while the skin was closed with undyed Vicryl 3/0.
Local anaesthesia was subsequently given and an adhesive dressing was applied over the area
of incision. The thyroid specimen was sent for histopathological anaylsis.

Post op
After the thyroid surgery, patient was admitted back to the ward for overnight
observation to manage pain, nausea, and monitor for hypocalcemia or hematoma formations.
Postoperative plan include
- Monitor O2 administration, pulse oximetry for oxygen saturation to prevent early
postoperative respiratory dyspnea
- Appropriate pain control (Tramadol HCL 50mg capsule TDS given for 3 days) and to
continue analgesic upon discharge
- Paracetamol 500mg tablet QID for 5 days
- To allow orally after conscious
- Evaluate the patient for any unusual voice changes, subtle hypocalcemic symptoms,
and overall recovery.
- Wound inspection on day 3 to look for hematoma
- Right vacuum drain charting
- No need to remove surgical suture for (Suture-to-off)
- Review surgical pathology results
- Discuss plans for further treatment or observation.
- If thyroid malignancy is found on histopathology report, coordinate multidisciplinary
care for patients with thyroid cancer. Depending on size, completion of left
hemithyroidectomy is placed in view with lifelong thyroid hormone replacement with
/ without calcium supplementation.

Upon attaining consciousness, patient was resting well accompanied by her family member
and had taken diet orally without any complaints made. Patient’s vital signs are all normal and
she is afebrile. There’s good hydration. Postoperatively, there’s no vomiting, pain or tachypnea,
but however mild hoarseness of voice is noted in the patient. On examination of the neck,
dressing is stained but not soaked. On post op day 1, 60cc of hemoserous fluid was seen in the
vacuum drain. On post op day 2, 10cc of hemoserous fluid was drained.
After a 4-day hospitalization, the drain was removed and wound was inspected on post op
day 3 – no signs of hematoma or thrombophlebitis seen. Ms. W was then discharged with
continuation of tramadol for pain management. The patient will be reviewed after a week for
counselling.

Discussion of case
A few discussion points have been thought on, and discussed below.

Could we determine if a thyroid nodule is benign or malignant on physical examination?

Physical characteristics of a thyroid nodule are poor predictors of malignancy; both
malignant and benign solitary thyroid nodules can be soft or firm, smooth or irregular upon
examination although in contrast, a study by Uyar et al indicated that characteristics such as
irregular borders, microcalcification, increased vascularity, and cervical lymphadenopathy are
malignancy risk factors for solitary thyroid nodules. However, increased size of a thyroid
nodule correlates with increased risk of malignancy. Moreover, size is used in tumor staging
and is highly predictive of outcome.

In this patient where she has a thyroid mass, is it possible for us to see a normal size thyroid
gland?
The old (1960) palpation criterion for goitre: “lobes larger than the terminal phalanxes of
thumbs”. According to WHO 5 stage Goitre grading system,
- Grade 0 : This is when the goitre is not palpable or visible even when the neck is
extended.
- Grade 1: Has 2 divisions, when the goitre is palpable
- Grade 1A: Goitre detected on palpation
- Grade 1B: Goitre palpable and visible when neck extended
- Grade 2: Goitre visible when neck is in the normal position
- Grade 3: Large goitre visible from distance

Goitres become visible when they are 3 times the normal size (weighing more than 50g).
According to Harrison’s Endocrinology, it fights the earlier dogma that maintained that a
palpable thyroid indicate goiter or disease because the normal gland usually cannot be
visualized or palpated. Hence, tt would be diseased if the thyroid gland is visual on inspection.
If radionuclide scanning is indicated in this case, what does it tell?
A key determination is whether the nodule is hyperfunctioning (or “hot”), which is
associated with a low (<5%) risk of malignancy. A low thyroid-stimulating hormone level is
consistent with a hyperfunctioning nodule but could also be seen with other disease processes,
such as a multinodular goiter or Graves disease. Radionuclide scanning involving either iodine-
123 or Tc-99m is required to determine whether a nodule is hyperfunctioning and therefore
taking up the radiotracer to a greater extent than the surrounding thyroid gland. The use of
iodine is preferred over Tc-99m when the diagnostic scan is performed in preparation for
therapeutic radioactive iodine ablation of the hyperfunctioning nodule.
If the nodule is hyperfunctioning, the risk of malignancy is sufficiently low to obviate the
need for a fine-needle aspiration, although the hyperthyroidism should be treated with
antithyroid drugs or with thyroid ablation using radioactive iodine. If a nodule >1 cm is not
taking up the radiotracer (a “cold” nodule), it should be evaluated by means of ultrasound-
guided fine-needle aspiration to rule out malignancy.

In this case whereby patient suffered a little hoarseness, is this normal?

Hoarseness is common after thyroid surgery. Transient hoarseness that resolves
spontaneously in 24 to 48 hours is typically due to vocal cord edema caused by endotracheal
intubation. Persistent or severe hoarseness is rare and can be caused by arytenoid dislocation
or vocal cord dysfunction from a nerve injury.
According to the latest 2017 endocrinology journals, the rate of recurrent laryngeal
nerve injury in terms of total paralysis is 6% while partial paralysis is around 40%. As for
Malaysia, the statistics range around 3-4% for total, while partial is only 20%. This goes to
show how important it is, the length of preservation of recurrent laryngeal nerve is so
importantly practiced in Malaysia, which is a good thing.
Symptomatic voice changes generally improve after the immediate postoperative
period. Hoarseness, uncontrolled coughing when talking, dyspnea that persists for more than
24 to 48 hours after surgery, or aspiration pneumonia should raise suspicion for possible vocal
cord motion abnormalities. Such patients should be referred promptly for direct laryngoscopy
and a complete neurolaryngeal evaluation.

What is the role of frozen section in this patient’s course?

Frozen section analysis during thyroid surgery should only be employed when it will have an
impact on surgical decision making. In this case I would say its not necessary because patient’s
clinical features very largely suggests multinodular goiter. However, if ultrasound features has
a higher suggestive risk for malignancy i.e. hypoechoic nodules >10mm, irregular margins,
chaotic intramodular vascular spots, more-tall-than-wide shapes, microcalcifications,
extracapsular growth, frozen section can help the surgeon intraoperatively to decide if this
patient needs widening of resection margin.

Final Diagnosis
Dominant right thyroid nodule in a multinodular goiter

Recovery is usually complete since patient has underwent hemithyroidectomy. Many

of the signs and symptoms are consistent with the features of this case, hence consistent with
the diagnosis.
Discussion of Professionalism, Ethics, Patient Safety and Communication Issues
I have obtained the necessary patient consent where the patient has given her approval
for participation in this case write up, followed by representation of her clinical details in this
possible circulated document. She understands that I, as writer of this case will ensure that
her identity won't be revealed with anonymity guaranteed.
In terms of patient safety, and coming to learn deeply about postoperative
complications of surgery and in this case hemithyroidectomy, I have learnt one thing – in any
field of practice, close monitoring of patient after procedure is important and should not be
hasty in necessitating quick discharge as we may not have take into account that patients
clinical picture might turn bad.
In terms of professionalism, as patient is discharged at the end of the writing of this
case, the principle of “continuity of care” applies. As this patient has been under my watch
ever since I clerked her on the day of her admission, I have continued to follow up on her
progress, checking with from day to day with her, and seeing the progress of how her she
improved throughout the course, until she makes a full good recovery with satisfaction that
her neck swelling has been removed. In fact, the close relationship between this patient and I
that have developed throughout this patient encounter, brings much trust to her, that she got
my phone number at the end prior to discharge so that she could report her clinical progress
to me upon her request. Even after discharge, I kept in close contact with her through
telephone to ensure that she is well.
This is a particular important value especially in future practices, that we treat all
patients the way how we wish we be cared for. To quote, Rachel Naomi Remen simply put it
“The healing of our present rounded may lie in recognising and reclaiming the capacity we
all have to heal each other, the enormous power in the simplest of human relationship, the
strength of a touch, the grace of someone else taking you just as you are finding in you an
unexpected goodness”.
In addition to that, as a medical student, I took the opportunity and advantage during
her hospital stay, to advise her to go for regular mammogram. This is because she has a
family history of breast cancer and currently Ms. W is at the age where risk of cancer is
rather high. I’ve explained to her the benefit of mammogram as well as sharing with her on
how to do self-examination regularly.
The clerking with Ms. W was smooth, there was no language barrier as I was able to
converse English well with him. Having a close relationship with the patient is important in
my opinion when it comes to building a good bridge of communication. Without fortifying
trust in communication, it would have been difficult for Ms. W to tell me exactly what
happened to her and the adversity that she has gone through within the 11 months where she
suffered emotionally from the neck swelling.
When I was clerking Ms. W, she spent quite some time to tell me about how her life
has been before and after the neck swelling. When Ms. W was rejected by the attending
physician previously on surgical removal, the emotional toll on her was so great that she
experienced so much stress, leading to the inexplicable weight loss, loss of appetite and loss
of sleep quality. From there, I learned that having a neck swelling like that even though
sometimes benign, we need to take patient’s psychological factor into consideration, offering
appropriate treatment to our patients from time to time, on case to case basis. In Ms. W’s
case, hemithyroidectomy to remove the right thyroid mass. As little importance as this may
seem, behind the curtains sometimes patient’s mental wellbeing is far more important than
we may expect.
Finally, one thing to take heed from this is the importance of a medical team.
Especially in Ms. W’s case where she had an endocrine disorder, many doctors or healthcare
providers’ from different specialty matters, and had it not been for the frequent round-the-bed
discussion by the doctors and nurses together, pulling all healthcare team mental resources
together from both surgery, endocrine, anaesthesia, nutrition, radiologist, it would been a lot
worse.
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