Breast and

Endocrine Surgery
Case Report

Student Name: Mohammed alrubaiaan

University ID: 170288
Patients Information:

 MRN: 00934185
 Room: Ward 400 – Room 416- KSMC
 Name: Zabia Maid Al-Qahtani
 Age: 34 years old
 Gender: Female
 Nationality: Saudi

Chief Complaint:
Neck swelling

History of Presenting Illness:

Zabia is a 34 year old Saudi Female medically free from Riyadh. She admitted to hospital
complaining neck mass before 10 years , mass not increasing in size. During her last pregnancy
she complained of shortness of breath and dysphagia to liquids that reduced significantly after
delivery. She has Numbness and tingling of right arm, Palpitations , Insomnia ,
Shivers/tremors,and Irregular menstruation

Associated Symptoms:
Numbness and tingling of right arm
Palpitations
Insomnia
Shivers/tremors
Dysphagia – liquids
Shortness of breath – sleeps elevated on 2 pillows
Irregular menstruation
Past Medical History:
 Medically free

Past Surgical History:

 Three C sections

Vaccinations & Allergies:

 No known allergies
 Didn’t receive her annual vaccination
 Covid vaccine up to date

Medications:
 No medications
 No herbal medications

Family History:

▪ Her brother has hypothyroidism for which he underwent thyroidectomy

Social History:

▪ Patient married

▪ Gravida 3 para 3

Review of Systems:

▪ General: No fever, night sweats or loss of appetite, weight gain of 20 kg

▪ HEENT: No dizziness or confusion or headache

o Eyes: No history of altered vision

 o Ears: No pain or hearing loss
o Nose: No history of epistaxis or change in smell.
o Throat: dysphagia and dyspnea, No history of recent sore throat or oral ulcers.

▪ Cardiovascular: No chest pain or palpitations.

▪ Respiratory: positive for shortness of breath. No cough.

▪ Gastroenterology: no nausea, vomiting or abdominal pain

▪ Genitourinary: No urgency, dysuria or abnormal discharge.

▪ MSK: No joint pain.

▪ Dermatology: No rashes or skin changes.

Physical Examination:

▪ Vital Signs:

▪ Temperature: 36.7oc oral

▪ Pulse: 100 bpm

▪ Respiratory rate: 20 breaths/min

▪ Blood Pressure: 120/80 mmHg (right brachial)

▪ O2 Saturation: 95% on Room Air

▪ Pain score: 6/10

 General Exam:
o Patient was alert and well oriented, looks well
 o Hands: No pallor, nail clubbing, onychorrhexis, muscle wasting, koilonychia or
peripheral cyanosis. Normal capillary refill and Radial Pulse had regular rhythm and
normal volume. No tremor, clubbing, sweating or warm hands. No skin changes.
o Eyes: No conjunctival pallor, no scleral icterus though. No lid retraction, lid lag or
exophthalmos. Eye movement is normal and there is no proptosis.
o Neck: palpable submandibular lymph node on the left side
o Legs: No lower limb edema.

 Chest Examination
o Respiratory:

▪ Inspection: Symmetric chest movement; no deformities, or gynecomastia

or abnormal hair distribution.

▪ Palpation: Normal chest expansion; No tracheal deviation

▪ Percussion: Resonant on all lung fields.

▪ Auscultation: Normal air entry bilaterally, vesicular breathing with no

added sounds bilaterally.

o CVS: Normal S1, S2 with no added sounds. No heaves or thrills or deviation of
PMI

 Abdominal Examination:
o Inspection: C section scar
o Palpation: Soft and lax and No tenderness, palpable masses or organomegaly.
o Percussion: Tympanic throughout. No shifting dullness.
o Auscultation: Normal bowel sounds; no bruit was heard over the abdominal aorta
or the renal arteries.
o Digital Rectal Examination: Unremarkable
  Head and Neck Examination:
o Neck swelling left bigger than right
o Lymph node palpable sub mandibular lymph node on left side

Investigations
 Labs:
 LYM 2.39 10^9/L
 MONO 0.56 10^9/L
 WBC 7.5 10^9/L
 RBC 5.15 10^12/L
 Hb 12 g/dl
 HCT 37.2%
 MCV 72.2 fL
 MCH 23.3 pg
 MCHC 32.3 g/dL
 RDW 16.1%
 PLT 231 10^9/L
 Neutrophils 59.2%
 Lymphocytes 31.9%
 Eosinophils 1.1 %
 Basophils 0.3%
 Monocytes 6.0%
 PT 12.9 sec
 PT INR 0.94 sec
 PTT 29.8 sec
 BUN 6.9 mmol/L
 Creatinine 51 umol/L
 Uric Acid 315 umol/L
 Na 138 mmol/L
 K 4.02 mmol/L
 Cl 103 mmol/L
 Ca 2.3 mmol/L
 AST 11.7
  ALT 13.6
 Albumin 44.6 g/L
 Calcium 2.1 mmol/L
 Phosphorus 1.24 mmol/L
 Magnesium 0.7 mmol/L
 Alkaline phosphatase 90 U/L

Imaging:
 Ultra sound findings: isthmus 0.47cm. Right lobe : 5.45x1.55x1.77cm = 5.22ml.
Left lobe : 7.78x6.33x4.25 = 110ml. Both show diffuse heterogenicity and normal
vascularity, bilateral multiple well defined heterogeneous nodules of variable sizes.
Largest one is : 7.78 x 4.25 cm in left lobe
 Tirad 3 for FNA
 Bethesda type 2

 CT FINDINGS:
Left lobe of the thyroid is grossly enlarged with heterogeneous enhancement which is medially
extended to involve the isthmus and is measuring about
width of 0.2 side, The 8,3 cm in the vertical height. The trachea is at displaced on the right side
and showing significant compression on the left side.
Retrosternal extension of the left lobe of the thyroid noted and measuring about 10 mm below
the manubrium steri level.
No nasopharyngeal mass is seen but palatine tonsils are mildly enlarged.
Enlarged lymph node seen at level I B (retromandibular region )measuring on rt side about
15x17 mm and on left side about 9x13 mm . Other lymph
Nodes are subcentmetencin nalure
Laryngeal column is normal with normal vocal cords and laryngeal cartilages are preserved.
No bony lesions seen in the cervical spine and visible facial bone is also made of the history of
previous previous. The. There is which was sent rest of
the pelvis of the anterior
IMPRESSION:
Grossly enlarged left lobe of the thyroid gland is normal with heterogeneous enhancement and
causing significant compression on the
trachea from the loft side and also showing retrosternal extension for about 10 mm below the
manubrium.
Bilateral palatine tonsils are mildly enlarged and onlarged lymph node son at level I B as
described
Final Diagnosis:
Multi-nodular goiter

Hospital Course and Plan:

Goals: Total thyroidectomy on 13/11/2022
 Pre Op order:
 Keep pt NPO 8 hours before Operation
 Paracetamol 1g IV Q6 PRN
 D5 ½ N S 120 cc 1h during midnight
 Cephazin 2g on call to OR

 STATUS POST thyroidectomy: Day 1

 Seen today 14/11/2022, doing fine no hypocalcemic signs, talking, tolerating orally, no
voice fatiguability with clear voice, passing urine but no bowel motion yet. O/E: pt
conscious alert oriented , vitaly stable : T 36.6 , BP141/82, P 76, spo2 98. Labs: Ca 2.18
Po4 0.96 Mg 0.76 Albumin 36.8 plan: CaCo3 1000mg po tid, Heparin 5000 IV, Hold
tramadol, bone profile, wound clean no sign of infection

 Day 2 patient doing well fit for discharge, discharged at 10 am. Given Thyroxine 150
mcg. Booked for follow up in 2 weeks