CASE PRESENTATION

Presenter : Dr. Nagaraju

 Chief complaints
• A 32 year old female patient from Muthkur
came to the hospital with

Chief complaints of
 Swelling in front of the neck since 2 years.
 History of present illness
• She was apparently normal 2 years back when
she started noticing a small swelling in front of
the neck which gradually progressed to the
present size
• No h/o difficulty in swallowing / palpitations /
dyspnoea/hoarseness of voice / changes in
appetite / tremors / muscle weakness
• No h/o intolerance to heat / weight loss
• No h/o chest pain / irritability / dizziness
• No h/o fever
• No h/o drug intake in the past / exposure to
radiation
• No h/o constipation / diarrhoea
• No menstrual irregularities / sleep
disturbances / myalgia / mood changes
• No h/o hemoptysis
 Past history
• No similay history in the past
• No surgery / anaesthetic exposure in the past
• No drug allergies
• No known co morbidities like DM/HTN/Pulm.
TB/Br. Asthama
/Seizures/Jaundice/Malignancy
 Menstrual history
• She attained menarche at 12 years of age
• Regular cycles with 3-4 days of normal flow
every 30 days
• No dysmenorrhea
 Personal history
• Pt. consumes mixed diet
• She is married & has 2 children
• No addictive habbits
• Bowel & bladder habits are normal
• No history of goitrogens intake
Medication history

• No history of medication usage in the past

Family history

• No similar / other health complaints in the

family
 General physical examination

• A 32 year old female patient, moderately built

& nourished, conscious, coherent,

cooperative, well oriented to time, place &

person
 Vitals
• Pulse – 88 beats / min., regular in rhythm, high
in volume, codition of vessel wall is normal, all
peripheral pulses are felt. No RF / RR delay
• BP – 110 / 60 mm of Hg, measured in right arm
in supine position
• Respiratory Rate – 16 / min.,thoraco abdominal
type
• Temperature – 980 F
• SpO2 – 98 % in room air
 Head to toe examination
• No signs of pallor, icterus, clubbing, cyanosis,
lymphadenopathy & edema
• Hair – normal
• Skin – warm and moist
• Nails – normal
• Oral cavity – normal
• Eyes – normal
 Airway examination
• Mallampati grading - II
• Thyro mental distance - > 3 fingers
• Mouth opening > 3 fingers
• Neck movements are normal
• No loose or missing teeth & no dentures
• Vertebral column – normal
• Temporomandibular joint – normal
• Trachea – central
 Local examination
• Inspection – Pizzillo method
 Pt. was asked to clasp the hands and place behind the
head. She was then asked to push her head backwards
against the clasped hands
 Diffuse swelling in front of the neck.
 Butterfly shaped.
 About 5*3 cm., extending on either side of midline,
laterally upto the medial border of sternocleidomastoid.
 Superiorly 2 cm., above the thyroid cartilage.
 Inferior border extending 1cm., above the supra sternal
notch
 Swelling moved upwards with deglutition
 Swelling was not moving with protrusion of
tongue
 Trachea appears to be in the midline
 No engorged veins
 Pemberton sign is negative
 No scars, sinus or other swellings in the neck
• Palpation :
 From behind :
 Palpation done with slight flexion of neck
 No local rise in temperature
 No tenderness
 All inspectory findings are confirmed
 Surface of swelling is bosselated, firm in
consistency, freely mobile
 Skin over the swelling is normal
 No regional lymph nodes are palpable
 From front :
 Done with slight extension of neck
 Each lobe is palpated by Lahey’s method
 Size of swelling is 5*3 cms..
 Mobile in vertical & transverse direction.
 Moves with deglutition
 Skin over swelling is mobile
 Able to get under the swelling
 Trachea is in midline
 Kocher’s test is negative
 No other swellings felt
 Carotid pulse felt
• Percussion :
 On manubrium of sternum gives resonant
note.
 No tenderness

• Auscultation :
 Pt was asked to hold the breath
 No bruit present over the swellings
 CVS examination
• Apical impulse felt at 5th inter costal space
inside the mid clavicular line
• On auscultation S1, S2 heard
• No murmurs were heard
 Respiratory System Examination
• Chest is uniform, bilaterally symmetrical
• No drooping of shoulders
• No spine deformities
• No swellings, scars, visible pulsations
 Per abdomen examination
• Abdomen is scaphoid & flat in shape
• All quadrants move equally with respiration
• On palpation abdomen is soft, no tenderness,
no local rise of temperature , no
organomegaly
 CNS examination
• Higher motor functions are normal
• Cranial nerves intact
• All sensory & motor abilities are within normal
limits
• Reflexes are within normal imits
• Cerebellar functions are normal
• Skull & spine are normal
 Provisional diagnosis
• Multinodular goitre with clinicaly euthyroid
state
 DD
• Thyroglossal cyst
• Lipoma
• Dermoid cyst
• Subhyoid bursitis
• Pretracheal cervical lymphnodes
• Cystic hygroma
• Branchial cyst
• Ranula