06/03/22
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A 54 year old male presented with swelling in right side of neck.
K.Lasya Mithra, 9th semester
Roll No: 50
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
CASE:
A 54 year old Male presented to hospital with chief complaint of swelling in right side of neck from 10 months.
History of present illness:
Patient was apparently asymptomatic 10 months back then he noticed a swelling in right side of neck which is insidious in onset , gradually progressive to present size.The swelling moves up with deglutition and doesn't move with protrusion of tongue.
No history of pain, difficulty in swallowing, difficulty in breathing, hoarseness of voice, trauma.
No history of weight loss or weight gain, heat or cold intolerance, excessive sweating, diarrhea or constipation, palpitations.
No history of cough with expectoration, abdominal pain and distension, bone pains, chest pain.
Past history:
He is a known case of diabetic from 12 years and on regular medication (combination of glimeperide, pioglitazone, metformin)
No history of asthma , hypertension, epilepsy, tuberculosis, cardiovascular diseases.
History of surgery on scalp for hemangioma - 5 years back.
Personal history:
Appetite - normal
Diet - mixed
Bowel and bladder - regular
Sleep - adequate
Addictions - consumes alcohol 90 ml occasionally ( stopped 2 months back), stopped smoking 10 years back.
Family history: insignificant
GENERAL EXAMINATION:
patient is conscious, coherent and cooperative with well oriented to time, place and person.
Moderately built and nourished
There is no pallor, icterus, cyanosis, clubbing , lymphadenopathy.
pedal edema - Present (upto knee)
No lid lag and lid retraction and exopthalmas.
No tremors seen on outstretched hand and tongue.
Vitals:
- Temperature - afebrile
- Pulse rate- 80 bpm
- Respiratory rate - 18 cpm
- Blood pressure - 120/80 mm hg
SYSTEMIC EXAMINATION:
Cardiovascular system:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation, S1 S2 heard No murmurs
Respiratory system:
Trachea- central
Bilateral air entry present
Normal vesicular breath sounds heard.
Per abdomen:
soft , non tender
Umbilicus - inverted
All quadrants moving equally with Respiration
No scars , sinuses, engorged veins
No palpable spleen and liver
Normal bowel sounds heard.
Central nervous system:
All higher mental functions, motor system, sensory system and cranial nerves- intact.
No focal neurological decifit.
LOCAL EXAMINATION:
Patient examined in a well lit room after taking consent.
Inspection:
A solitary oval swelling of 5x 4 cm seen on right side of neck with smooth surface , regular margins.
skin over swelling and surrounding skin appears normal. Swelling moves up with deglutition.
Trachea appears to lie in central position.
Palpation:
No local rise of temperature and no tenderness.
Inspectory findings about size , shape and extent are confirmed.
Suface is nodular and consistency is variable ( soft to firm)
Lower margin is palpable and swelling is mobile both horizontally and vertically.
Bilateral carotid pulsations are felt and no enlarged lymph nodes.
DIAGNOSIS: Multinodular goiter
INVESTIGATIONS:
CBP:
Hb - 14.8 gm/dl
TLC - 6100 cells/ cumm
RBC - 4.4 million
PLT - 2.24 lakh
THYROID PROFILE:
T3 - 1.05 ng/ml
T4 - 15.2 mcg/ dl
TSH - 0.83
RFT:
urea - 25 mg/dl
Creatinine - 1.0 mg/dl
Uric acid- 5.9 mg/dl
Electrolytes:
Na - 142 mEq/L
K - 4.4 mEq/L
Cl - 106 mEq/L
LFT :
Total bilirubin- 0.77 mg/dl
ALT - 31 IU/L
AST - 23 IU/L
ALP - 122 IU/L
albumin - 3.9 gm/dl
A/ G ratio - 1.45
ECG:
X-RAY:
CT :
USG OF NECK:
Impression:
Right side - has colloid cyst of 6x3 cm
Left lobe- 1.5 x 2cm lesion seen
FNAC:
Colloidal aspiration of 0.5cc from left and 3ml from right with blood mixed.
Findings: Cytosmear studies show adequate cellularity comprising of thyroid follicular cells arranged in small sheets, clusters and scattered individually.
Impression: Left- Benign colloidal goitre
Right- Nodular goitre
DIAGNOSIS :
Right lobe- colloid goiter and left lobe - nodular goitre in clinically euthyroid state.
MANAGEMENT:
FNAC was repeated again under USG guidence report awaited.
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