CASE WRITE UP

Department of Surgery
Cyberjaya University College of Mei!al S!ien!es
MU"TI#$DU"AR %$ITRE
#ame& 'armeet (aur a)p Daleep Sing*
Matri! #o+& ,-,./0123
4ear)%roup& 4ear 2)%roup 3
Supervisor& Mr A*me A5il Aam
Core Component %iven Mar6s
'istory
P*ysi!al E7amination
Investigation
Provisional Diagnosis)Differential Diagnosis
Dis!ussion& Ientify problems8 management an
progress of patient
Referen!es
0+ 'IST$R4
0+0 Demograp*i! Data
1
Patient Name: Maslina Bt Ahmad
Age: 66 years old
Sex: Female
Origin: Batu Pahat, Johor
Date of admission: !
th
De"em#er $%%
Date of &ler'ing: ($th De"em#er $%%
Pla"e of "ler'ing: Putra)aya *os+ital
0+1 'istory of Presenting Illness
&hief "om+lain: Madam Maslina +resented to the ,mergen"y De+artment follo-ing an
e+isode of shortness of #reath -hi"h lasted a#out half an hour on !
th
De"em#er $%%
Madam Maslina.s history dates #a"' to year $$$ -here she first noti"ed a ne"' s-elling
on #oth sides of her ne"'/ 0t -as relati1ely small si2ed, -ith the right side #eing #igger than the
left side/ 0t -as not +ainful and felt li'e multi+le, small, seed li'e s-ellings 3in her -ords4 on her
ne"'/ 0t -as soft and mo#ile too/ 5here -as no dis"harge or ul"ers at the site of s-elling and
neither -as it it"hy or asso"iated -ith any e"2ema/ She noti"ed the s-elling a fe- months after
she had deli1ered her 6
th
"hild/ At that time, she also had lethargy and had lost -eight, a#out !'g
in the s+an of ( months/ She also had heada"he on and off/ *er food inta'e -as the same though,
-ith no in"rease or de"rease in a++etite/ She did not eat mu"h seafood either/ She had no heat or
"old intoleran"e, diffi"ulty in #reathing or dys+hagia at that time either/ She did not noti"e any
o1ert s-eating or tremors as -ell/ 5here -as also no "hange in 1oi"e, diarrhea, +al+itations or
s-elling any-here else on her #ody/ *er systemi" re1ie- -as unremar'a#le at that time/
2
Due to her ne"' s-elling, she -ent to Batu Pahat hos+ital at that time 3year $$$4 to see
the do"tor and -as told that she most +ro#a#ly had a +ro#lem -ith her thyroid gland #ut nothing
-as done and no medi"ations -ere gi1en either/ 5he s-elling gradually in"reased in si2e o1er the
years #ut she did not thin' that it -as serious as she didn.t noti"e it #e"oming #igger until year
$$7 -here she -as s"heduled to do a surgery 3thyroide"tomy4 in Batu Pahat hos+ital #ut the
surgery -as +ost+oned as her thyroid hormone le1els -ere high/ *en"e she -as dis"harged -ith
medi"ations to sta#ili2e her thyroid hormone le1el and -as as'ed to "ome #a"' again after a year
and a half/ She defaulted her follo- u+ though/
No-, in De"em#er $%, she +resented to the ,D of Batu Pahat hos+ital -ith SOB -hi"h
o""urred at rest and lasted till she got to the ,D, -hi"h -as a#out half an hour/ 0t had a sudden
onset and -as asso"iated -ith syn"o+y -hi"h o""urred -hile she -as on the -ay to the hos+ital/
5he syn"o+y lasted a#out a fe- minutes though and she gained "ons"iousness in the ,D/ She
e1en had fe1er %8 days +rior to admission -hi"h -as intermittent in nature/ She did not ta'e any
medi"ations to relie1e her fe1er though/ She had no +rior e+isodes of dys+nea, ortho+nea or
+aroxysmal no"turnal dys+nea #efore this/ She did not ha1e any leg s-elling or "hest +ain and
did not ha1e dys+hagia +rior to admission either/ *er ne"' s-elling -as no- mu"h #igger in
si2e, a#out %!"m in length/ She had lost more -eight o1er the years, gradually though #ut did not
remem#er the amount/ Systemi" re1ie- -as unremar'a#le/
0n Batu Pahat hos+ital, they too' a long time to intu#ate her as it -as diffi"ult to do so
and referred her to Putra)aya *os+ital on that day itself/
0+2 Past Mei!al 'istory
She -as diagnosed to ha1e hy+ertension in $$7 during her routine "he"'u+/ She does
not ha1e any other "hroni" illnesses though/ She had not gone for any surgery #efore this either/
0+9 :amily 'istory
3
*er +arents ha1e +assed a-ay/ *er father had asthma -hile he -as ali1e -hile her
mother had hy+erthyroidism, hy+ertension and dia#etes mellitus/ She has 6 si#lings -hose ages
range from 6$8!$ something years old/ *er #rother has hy+ertension and dia#etes mellitus -hile
her sister has rheumatoid arthritis and dia#etes mellitus/ *er other younger sister has
hy+erthyroidism too/ She is married -ith ! "hildren -hose ages range from !8$ years old/ 5hey
are all healthy/ *en"e, the ones -ith similar +ro#lems as her are her younger sister and mother/
0+3 Drug 'istory
She used to ta'e medi"ations #ut only from year $$7/ She ta'es a medi"ation to redu"e
her thyroid hormone le1els and is on anti8hy+ertensi1es/ She does not remem#er the name of her
drugs though/ She is not "om+liant to her anti8hy+ertensi1es though as she ta'es them -hen she
has heada"hes only/ She is not allergi" to any drugs and has not ta'en any traditional medi"ine
+re1iously/
0+; So!ial 'istory
She does not smo'e nor "onsumes al"ohol/ She li1es -ith her "hildren and is generally
-ell loo'ed after/ She is married -ith ! "hildren and her hus#and is still -or'ing as a "ontra"tor/
She is a "aterer and has a food #usiness of her o-n/
1+ P'4SICA" E<AMI#ATI$#
4
1+0 %eneral Inspe!tion
Post8o+
On general ins+e"tion, she -as "ons"ious and -as sitting u+ "omforta#ly on her #ed and
-as using a nasal +rong/ She -as not in res+iratory distress and -as alert/ She -as orientated to
time and s+a"e/ She also had a #ranula inserted on the dorsal +art of her hand and she -as on
&BD/ *er +alms -ere slightly moist/ 5here -as no "lu##ing or any other nail "hanges/ 5here
-as slight tremor though/ She -as not +ale or )aundi"ed and there -as no "entral or +eri+heral
"yanosis/ She -as slightly dehydrated though/ *er fa"e is not edematous/
1+1 =ital signs
9+on admission:
BP: %!:;76 mm;*g
*eart rate: %$(;min
<<: (!;min
Post = o+
5
BP: %($;:!
*eart rate: :6;min
<<: %6;min
1+2 #e!6 e7amination
Pre/op
9+on ins+e"tion of her ne"', there is a s-elling on #oth sides of the ne"', -ith the right
side #eing #igger than the left/ 0t extends )ust a#o1e the su+rasternal not"h and lies dee+ to the
sterno"laidomastoid mus"les/ 5he s'in o1er the s-elling is not red> there are no s"ars or e"2ema/
5here are slightly dilated 1eins 1isi#le on either side of the s-elling/ 5here are no sinuses or
dis"harge from the s-elling/ 5here are no 1isi#le +ulsations either/ 5he s-elling mo1ed u+-ard
-ith s-allo-ing/
9+on +al+ation, the s-elling -as of normal tem+erature and -as not hot/ 5he right lo#e
measured $x! "m -hile the left lo#e -as %!x%$"m/ 5he s-elling -as not tender, firm and
mo#ile/ 0t.s surfa"e -as nodular and the tra"heal rings -ere not +al+a#le at the su+rasternal
not"h/ 5here -ere no thrills noted on the su+erior +oles of the thyroid gland/ &arotid +ulse "ould
#e +al+ated, and it -as strong and +resent/
9+on +er"ussion o1er the manu#rium of sternum, dullness -as noted/ 9+on aus"ultation
of the su+erior +oles of the gland, no #ruits -ere noted/ 5here -ere no lym+h node enlargements/
Post/op
6
Post o+erati1ely, she has a fresh s"ar on her ne"' -ith 1isi#le stit"hes and no dressing/ 0t
is a hori2ontal s"ar measuring a#out %$"m/ 5here is a "atheter inserted at the o+erati1e area to
drain #lood from it/ *er 1oi"e is no- hoarse and she "an #arely -his+er out -ords/
1+9 Systemi! revie5&
,yes: slight lid retra"tion and infre?uent #lin'ing +re o+erati1ely, no exo+thalmos and she "an
"on1erge her eyes, no +tosis
&ardio1as"ular system: unremar'a#le
<es+iratory system: unremar'a#le
Neurologi"al system: unremar'a#le
@0 system: unremar'a#le
Pulses: all +resent and strong
Aegs: No +rete#ial myxedema, no +itting edema
2+ DIA%#$SES
2+0 Provisional Diagnosis
Multinodular goiter "ausing air-ay o#stru"tion
2+1 Differential Diagnosis
7
%/ 5hyroid "ar"inoma
/ @ra1es. disease
(/ Aym+hadeno+athy
9+ I#=ESTI%ATI$#S
9+0 Pre/$p >13t* De!ember 1,00?
%/ Full Blood &ount
Component =alues #ormal Range
5otal Bhite Blood &ells 02+. 368%%4 x %$
7
"ells
<ed Blood "ells 6/% 3(/:8!/!4 x %$
%
;A
*eamoglo#in %/ 3%8%:4 g;dA
*eamato"rit (!/! 3(68!$4 C
M&D :!/ 3:(8%$$4 fA
M&* 7/( 3E8(4 +g
M&*& (6/6 3(8(E4 g;dA
<DB 09+@ 3%$8%!4 C
Platelet "ount 09; 3%!$86$$4 x %$
7
;A
Neutro+hils 01+@ 3/!8E/!4 x %$
7
;A
Aym+ho"ytes ,+3 3%/$8(/!4 x %$
7
;A
Mono"ytes $/6 3$/8$/:4 x %$
7
;A
8
,osino+hils $ 3$/$68$/64 x %$
7
;A
Baso+hils $ (0.1.0.1) x %$
7
;A
/ <enal Profile
Component =alues #ormal Range
B9N @+3 3/!86/64 mmol;A
Na %6%/6 3%(8%664 mmol;A
F 6/6$ 3(/!86/!4 mmol;A
&l 000+9 37!8%$! 4 mmol;A
&reatinine :$ 3!(8%%!4 Gmol;A
(/ &oagulation Profile
Component =alue #ormal Range
P5 %/E %/68%6/E
0N< %/%66 H/$%
aP55 12+@ (%/E86%/%
6/ 5hyroid Fun"tion 5est
Component =alue #ormal Range
5( 6/77 3(/%8E/E4 +mol;A
56 %/%6 378(4 +mol;A
5S* ,+01- 3$/68(/$4 m9;A
9
!/ Minerals
Component =alue #ormal Range
Phos+hate %/(( 3$/:8%/!4 mmol;l
Magnesium 0+,; 3$/E!8%/$4 mmol;l
&al"ium 1+,- 3/%8/64 mmol;l
6/ &t s"an = retrosternal ex+ansion to le1el 5%85
9+1 Post op >1.
t*
De!ember 1,00?
%/ Full Blood &ount
Component =alues #ormal Range
5otal Bhite Blood &ells 03+@ 368%%4 x %$
7
"ells
<ed Blood "ells 2+29 3(/:8!/!4 x %$
%
;A
*eamoglo#in -+@9 3%8%:4 g;dA
*eamato"rit 1;+@ 3(68!$4 C
M&D @-+- 3:(8%$$4 fA
M&* 7/ 3E8(4 +g
M&*& (6/6 3(8(E4 g;dA
Platelet "ount 011 3%!$86$$4 x %$
7
;A
Neutro+hils 02+- 3/!8E/!4 x %$
7
;A
Aym+ho"ytes ,+;;3 3%/$8(/!4 x %$
7
;A
10
/ <enal Profile
Component =alues #ormal Range
B9N ;+@ 3/!86/64 mmol;A
Na %6%/ 3%(8%664 mmol;A
F (/6E 3(/!86/!4 mmol;A
&l %$!/: 37!8%$! 4 mmol;A
&reatinine 7! 3!(8%%!4 Gmol;A
(/ &oagulation Profile
Component =alue #ormal Range
P5 %(/7 %/68%6/E
0N< %/!! H/$%
aP55 13+@ (%/E86%/%
6/ Minerals
Component =alue #ormal Range
Phos+hate %/$$ 3$/:8%/!4 mmol;l
Magnesium $/:$ 3$/E!8%/$4 mmol;l
&al"ium 1+,; 3/%8/64 mmol;l
!/ Fasting Blood Sugar
11
=alue #ormal Range
0,+23 mmol;A H Emmol;A
6/ Ai+id +rofile
Component =alue #ormal Range
*DA %/( 3%/$8/4 mmol;l
ADA /6 3/$8(/64 mmol;l
5otal "holesterol 6/E 3(/$86/!4 mmol;l
5@ %/E 3$/68%/E4 mmol;l
E/ Bio+sy done of goiter done: results un'no-n
3+ DISCUSSI$#
12
5his +atient has a ne"' s-elling/ 5here are many "auses to ne"' s-elling su"h as:
Ba"terial
Ba"terial +haryngitis
Peritonsillar a#s"ess
Stre+ throat
5onsillitis
5u#er"ulosis
&an"er
*odg'inIs disease
Aeu'emia
Non8*odg'inIs lym+homa
5hyroid
5hyroid "ar"inoma
@oitre
@ra1esI disease
5hyroglossal du"t "ysts
5hyroiditis
Diral
13
A0DS
*er+es infe"tions
0nfe"tious mononu"leosis
<u#ella 3@erman measles4
Diral +haryngitis
Other
Allergi" rea"tions
0n this +atient, the "ause of ne"' s-elling is li'ely to #e due to her thyroid gland as her
history and the +hysi"al examination su++orts it/ *er "hief "om+lain of shortness of #reath
together -ith a 1isi#le ne"' s-elling is indi"ati1e of tra"heal "om+ression -hi"h is most
+ro#a#ly due to enlargement of the thyroid gland/ *er s-elling -as gradually in"reasing in si2e
for the +ast %% years and -as not +ainful/ No +ain indi"ates that it most +ro#a#ly "an.t #e
thyroiditis as that -ould "ause +ain/ 5he s-elling is also of a long standing one -hi"h also rules
out thyroiditis as thyroiditis usually "auses an a"ute s-elling/ She also des"ri#ed her s-elling to
#e Jmany small seed li'e s-ellings. -hi"h is indi"ati1e of a multinodular goiter/ 0t -as also soft
and mo#ile -hi"h meant that it is most +ro#a#ly not malignant as there is no fixation of the
s-elling to the s'in/ She had de1elo+ed it after gi1ing #irth to her 6
th
"hild -hi"h is a ris' fa"tor
for hy+erthyroidism too/ She also felt lethargi" and had lost !'g in the s+an of 6 months/ 5he
lethargy "ould #e due to in"rease meta#oli" rate of the #ody "ausing in"reased energy
ex+enditure and in"reased meta#olism also "auses the -eight loss/ 5he -eight loss also #rings in
the +ossi#ility of malignan"y #ut she did not lose too mu"h -eight as signifi"ant -eight loss in
her "ase -ould #e 6/6'g 3%$C of #ody -eight4/ *o-e1er, it "annot #e ruled out yet/
She also had heada"he on and off #ut this "ould #e due to her hy+ertension -hi"h she
de1elo+ed in year $$7/ A +atient -ith hy+erthyroidism "ould also ha1e in"reased #lood +ressure
as the thyroid hormone "an "ause a"ti1ation of the sym+atheti" ner1ous system/ She had no
14
+oly+hagia though, -hi"h is normally a sym+tom seen -ith hy+erthyroidism/ She does not eat
any seafood -hi"h means that her iodine le1el "ould #e lo- and this "an "ause goiter too/ She
had no heat intoleran"e either -hi"h indi"ates that her BM< is not too high/ She also did not
ha1e dys+hagia -hi"h is normally the su++orting sym+tom for retrosternal ex+ansion, ho-e1er
the SOB is ?uite indi"ati1e of that already/ *er SOB had also "aused syn"o+y/
SOB has many "auses related to the heart and lungs #ut 0 thin' that it is highly unli'ely as
she has no history of ortho+nea, dys+nea or PND #efore and neither does she ha1e any "hest +ain
or +edal edema/ She also does not ha1e any "ough -hi"h again rules out other "auses of SOB/
*en"e, gi1en her sym+toms -hi"h are more that of hy+erthyroidism, 0 sus+e"t that this is a "ase
of hy+erthyroidism -ith retrosternal ex+ansion/ She has a family history of hy+erthyroidism as
her mother and sister has it too/ She also ta'es anti8hy+ertensi1e drugs and anti thyroid drugs
-hi"h -ere #oth gi1en to her in year $$7 #ut she -as not "om+liant to either of them/ *en"e,
her ne"' s-elling in"reased in si2e and has "ause tra"heal "om+ression no-/ 9+on admission her
BP -as high, she -as ta"hy"ardi" and ta"hy+ni"/ 5he ta"hy"ardia and hy+ertension -as +ro#a#ly
due to her hy+erthyroidism -hile the ta"hy+nea -as "aused #y the tra"heal "om+ression #y the
thyroid gland/ 9+on examining her ne"', 0 noted that she had a large s-elling -hi"h -as #igger
on the right side rather than the left and had a nodular surfa"e/ 0t -as rather firm #ut -as mo#ile/
*er 1eins -ere also distended at the sides of the s-elling/ 5his "ould #e due to +ressure of the
internal )ugular 1eins in the thora"i" inlet #y the enlarged thyroid gland/ 5he s-elling mo1ed
-ith deglutition -hi"h is indi"ati1e that it -as the thyroid gland as the thyroid gland is en"losed
in the +retra"heal fas"ia -hi"h is fixed to the thyroid "artilage so -hen the su+erior "onstri"tor of
larynx +ulls the thyroid "artilage u+ during deglutition, the gland also mo1ed u+ and do-n/ Other
s-elling that mo1es -ith deglutition are thyroglossal "yst, +retra"heal lym+h nodes, su#hyoid
#ursa, and extrinsi" "a of larynx/
5he s-elling -as not tender and the tra"heal rings -ere not +al+a#le/ 5his is indi"ati1e of
a retrosternal ex+ansion/ 5o "onfirm it, 0 "ould ha1e "om+ressed her lateral lo#es -hi"h -ould
ha1e "aused stridor, indi"ating narro-ing of tra"hea due to the +resen"e of a s"a##ard tra"hea
due to "om+ression #y an enlarged thyroid gland #ut 0 didn.t do so as she -as already in
res+iratory distress/ On +er"ussion o1er the manu#rium sternum, dullness -as heard -hi"h on"e
again indi"ates retrosternal ex+ansion due to an enlarged thyroid gland/ She had the
15
hy+erthyroidism eye signs of lid retra"tion and infre?uent #lin'ing #ut she did not ha1e
exo+thalmos -hi"h indi"ates that she most +ro#a#ly does not ha1e @ra1es. disease/ *er other
systems -ere unremar'a#le -hi"h ruled out other reason of SOB su"h as +leural effusion and
there -as no lym+h nodes enlargement -hen 0 +al+ated her "er1i"al lym+h nodes -hi"h
indi"ates that the "ause of her s-elling is not due to lym+hadeno+athy either/ She also did not
ha1e +reti#ial myxedema -hi"h on"e again indi"ates that she "an.t #e ha1ing @ra1es. disease/
5hus my +ro1isional diagnosis is multinodular goiter as she had some sym+toms of
hy+erthyroidism su"h as a ne"' s-elling -hi"h -as gradually in"reasing in si2e for the +ast %%
years, lethargy, -eight loss, and heada"he and some signs too su"h as tremors, moist hands, lid
retra"tion and infre?uent #lin'ing/ 5he surfa"e of the ne"' s-elling -as also nodular, mo#ile and
+ainless -hi"h again su++orts the diagnosis/ She also had SOB and her tra"heal rings "ould not
#e +al+ated and her manu#rium sternum -as dull to +er"ussion -hi"h indi"ates a retrosternal
ex+ansion of the goiter/ All the other differentials -ere already ruled out a#o1e/
5his is "onfirmed #y the in1estigations es+e"ially the thyroid fun"tion test -hi"h sho-ed
that her 5S* le1els -ere lo- -hile her 56 and 5( le1els -ere normal -hi"h is due to her anti8
thyroid drugs that she has #een on sin"e year $$7/ *er total -hite #lood "ell "ount -as also
high, +ro#a#ly due to rea"ti1e leu"o"ytosis, and her "al"ium le1els are slightly lo- -hi"h on"e
again the surgeon must ta'e note as if "are is not ta'en during the surgery and her +arathyroid
glands are remo1ed, her "al"ium le1el -ould go lo-er still -hi"h "an "ause future "om+li"ations
su"h as osteo+orosis/ *er &5 s"an also "onfirms the diagnosis as it sho-s retrosternal ex+ansion
to le1el 5%85/ No- -e shall tal' a#out the thyroid gland, the hormone it releases and
hy+erthyroidism/
5he thyroid gland "onsists of t-o lateral lo#es "onne"ted #y an isthmus/ 0t is "losely
atta"hed to the thyroid "artilage and to the u++er end of the tra"hea, and thus mo1es on
s-allo-ing 3li'e ho- hers did4/ ,m#ryologi"ally it originates from the #ase of the tongue and
des"ends to the middle of the ne"'/ <emnants of thyroid tissue "an sometimes #e found at the
#ase of the tongue 3lingual thyroid4 and along the line of des"ent/
16
5hyrotro+hin8releasing hormone 35<*4, a +e+tide +rodu"ed in the hy+othalamus,
stimulates 5S* from the +ituitary/ 5S* stimulates gro-th and a"ti1ity of the thyroid folli"ular
"ells 1ia the @8+rotein "ou+led 5S* mem#rane re"e+tor/ &ir"ulating 56 is +eri+herally de8
iodinated to 5( -hi"h #inds to the thyroid hormone nu"lear re"e+tor 35<4 on target organ "ells to
"ause modified gene trans"ri+tion/
17
Physiologi"al effe"ts of thyroid hormones are:
&ardio1as"ular system 8 in"reased heart rate and "ardia" out+ut/
S'eletal 8 in"reased #one turno1er and resor+tion/
<es+iratory 8 maintains normal hy+oxi" and hy+er"a+ni" dri1e in res+iratory "entre/
@astrointestinal 8 in"reases gut motility/
Blood 8 in"reases red #lood "ell ,(8BP@ fa"ilitating oxygen release to tissues/
Neuromus"ular 8 in"reases s+eed of mus"le "ontra"tion and relaxation and mus"le +rotein
turno1er/
Meta#olism of "ar#ohydrates 8 in"reases he+ati" glu"oneogenesis;gly"olysis and
intestinal glu"ose a#sor+tion/
18
Meta#olism of li+ids 8 in"reased li+olysis and "holesterol synthesis and degradation/
Sym+atheti" ner1ous tissue 8 in"reases "ate"holamine sensiti1ity and K8adrenergi"
re"e+tor num#ers in heart, s'eletal mus"le, adi+ose "ells and lym+ho"ytes/ De"reases
"ardia" L8adrenergi" re"e+tors/
*y+erthyroidism 3thyroid o1era"ti1ity, thyrotoxi"osis4 is "ommon, affe"ting +erha+s 8
!C of all females at some time and -ith a sex ratio of ! : %, most often #et-een the ages of $
and 6$ years/ Nearly all "ases 3M 77C4 are "aused #y intrinsi" thyroid disease> a +ituitary "ause is
extremely rare/ 5he "auses of hy+erthyroidism are :
Common
@ra1esI disease 3autoimmune4
5oxi" multinodular goitre
Solitary toxi" nodule;adenoma
Un!ommon
A"ute thyroiditis
1iral 3e/g/ de Nuer1ainIs4
autoimmune
+ost8irradiation
+ost+artum
@estational thyrotoxi"osis 3*&@ stimulated4
Neonatal thyrotoxi"osis 3maternal thyroid anti#odies4
,xogenous iodine
Drugs 8 amiodarone
5hyrotoxi"osis fa"titia 3se"ret 56 "onsum+tion4
Rare
5S*8se"reting +ituitary tumours
19
Metastati" differentiated thyroid "ar"inoma
*&@8+rodu"ing tumours
*y+erfun"tioning o1arian teratoma 3struma o1arii4
5he most "ommon "auses of hy+erthyroidism are @ra1es. disease and multinodular goiter
3)ust as my +atient has4/ 5he differen"es #et-een the are as #elo-:
&hara"teristi" @ra1es disease Multinodular goiter
Autoimmune anti#odies +resent A#sent
O+thalmo+athy Present -ith exo+thalmos A#sent
Preti#ial myxedema +resent A#sent
Pers+iration More Aess
Age of +atient 9sually younger sin"e it is an
autoimmune disease
6$ years or older
&lu##ing &an o""ur if they ha1e
5hyroid a"ro+a"hy
A#sent
5hyroid enlargement Normally diffuse sim+le
goiter, not nodular
Nodular goitre, "an #e 1ery
huge
5ra"heal "om+ression 9n"ommon Dery "ommon
My +atient has a multinodular goiter/ @oitre is more "ommon in -omen than in men and
may #e either +hysiologi"al or +athologi"al/ Most "ommonly goiters are noti"ed as a "osmeti"
defe"t #y the +atient or #y friends or relati1es/ 5he ma)orities are +ainless, #ut +ain or dis"omfort
"an o""ur in a"ute 1arieties/ Aarge goitres "an +rodu"e dys+hagia and diffi"ulty in #reathing,
im+lying oeso+hageal or tra"heal "om+ression/ My +atient had a +ainless goiter -hi"h had
"aused tra"heal "om+ression/ 5he nature "an often #e )udged "lini"ally/ @oitres are usually
se+ara#le into diffuse and nodular ty+es, the "auses of -hi"h differ/ 5he "auses of goiter are
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Diffuse
Sim+le
Physiologi"al 3+u#erty, +regnan"y4
Autoimmune
@ra1esI disease
*ashimotoIs disease
5hyroiditis
A"ute 3de Nuer1ainIs thyroiditis4
0odine defi"ien"y 3endemi" goitre4
Dyshormonogenesis
@oitrogens 3e/g/ sulfonylureas4
#oular
Multinodular goitre
Solitary nodular
Fi#roti" 3<eidelIs thyroiditis4
&ysts
5umours
Adenomas
&ar"inoma
Aym+homas
Mis!ellaneous
Sar"oidosis
5u#er"ulosis
Most "ommon is the multinodular goitre, es+e"ially in older +atients, su"h as my +atient
-ho is 66 years old/ 5he +atient is usually euthyroid #ut may #e hy+erthyroid or #orderline -ith
su++ressed 5S* le1els #ut normal 56 and 5(/ 5his is also li'e my +atient -ho had lo- le1els of
5S* #ut normal le1els of 56 and 5( u+on admission/ Multinodular goitre is the most "ommon
"ause of tra"heal and;or oeso+hageal "om+ression and "an "ause laryngeal ner1e +alsy/ 5his also
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o""urred to my +atient as she had SOB/ 0t may also extend retrosternally, )ust li'e my +atient as
her tra"heal rings "ould not #e +al+ated and there -as dullness to +er"ussion of the manu#rium
sternum/ 5he "lassi"al Imultinodular goitreI is usually readily a++arent "lini"ally, #ut it should #e
noted that modern, high8resolution ultrasound fre?uently re+orts multi+le small nodules in glands
-hi"h are "lini"ally diffusely enlarged and asso"iated -ith autoimmune thyroid disease/ 5hese
nodules are also found in u+ to 6$C of the normal +o+ulation/
Malignan"y should #e "onsidered in any solitary nodule 8 ho-e1er, the ma)orities of su"h
nodules are "ysti" or #enign and, indeed, may sim+ly #e the largest nodule of a multinodular
goitre/ 5he diagnosti" "hallenge is to identify the small minority of malignant nodules, -hi"h
re?uire surgery, from the ma)ority of #enign nodules, -hi"h do not/ A history of ra+id
enlargement, asso"iated lym+h nodes or o""asionally +ain in su"h a situation suggests the
+ossi#ility of thyroid "ar"inoma, #ut in1estigations are +aramount/ <is' fa"tors for malignan"y
in"lude +re1ious irradiation, long8standing iodine defi"ien"y and o""asional familial "ases/ My
+atient did not ha1e any lym+h node enlargement and it -as not a solitary nodule/ 5hus, it "ould
not ha1e #een a malignan"y/
5he "lini"al sym+toms of hy+erthyroidism in general are tiredness, emotional la#ility,
heat intoleran"e, -eight loss, ex"essi1e a++etite and +al+itations/ 5he signs are ta"hy"ardia, hot,
moist +alms, exo+hthalmos, lid lag;retra"tion, agitation and thyroid goitre and #ruit/ 0ts
"om+arison -ith hy+othyroidism is illustrated as #elo-:
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My +atient only had goiter, -eight loss, tremors and moist +alms as she -as ta'ing anti8
thyroid drugs -hi"h "ontrolled the other sym+toms of hy+erthyroidism/
0n1estigations that should #e done if one sus+e"ts hy+erthyroidism are:
T*yroi fun!tion tests 8 5S* +lus free 56 or 5(
T*yroi antiboies 8 to ex"lude autoimmune aetiology/
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Ultrasoun/ 9ltrasound -ith high resolution is a sensiti1e method for delineating
nodules and "an demonstrate -hether they are "ysti" or solid/ 0n addition, a multinodular
goitre may #e demonstrated -hen only a single nodule is +al+a#le/ 9nfortunately, e1en
"ysti" lesions "an #e malignant and thyroid tumours may arise -ithin a multinodular
goitre> therefore fine8needle as+iration is often re?uired and +erformed under ultrasound
"ontrol at the same time as the s"an/
C*est an t*ora!i! inlet </rays to dete"t tra"heal "om+ression and large retrosternal
extensions in +atients -ith 1ery large goitre or "lini"al sym+toms/
:ine/neele aspiration >:#A?/ 0n +atients -ith a solitary nodule or a dominant nodule in
a multinodular goitre, there is a !C "han"e of malignan"y> in 1ie- of this, FNA should #e
+erformed/ 5his "an #e done in the out+atient "lini"/ &ytology in ex+ert hands "an
usually differentiate the sus+i"ious or definitely malignant nodule/
FNA redu"es the ne"essity for surgery, #ut there is a !C false8negati1e rate -hi"h must
#e #orne in mind 3and the +atient a++ro+riately "ounselled4/ &ontinued o#ser1ation is
re?uired -hen an isolated thyroid nodule is assumed to #e #enign -ithout ex"ision/
0n my +atient, they only did the thyroid fun"tion test/ 5hyroid anti#odies -ere not done
as it seemed highly unli'ely gi1en her age and the nature of her goiter/ 5hey did not ha1e to do
an ultrasound as a multinodular goiter -as already +al+a#le/ 5hey should ha1e done a "hest x8ray
to "onfirm the tra"heal "om+ression though and they should ha1e also done a FNA to rule out
malignan"y/ 5he rest of their in1estigations -ere )ustified though, su"h as FB& -as done to see
-hether there -as any infe"tion and -hether her *# and +latelet le1els are normal, gi1en that
she is s"heduled for surgery and this should #e re1ie-ed #efore sending her in to a1oid #leeding
+ro#lems/ <enal +rofile -as also im+ortant as she has hy+ertension and is not "om+liant to her
drugs, thus her 'idneys should #e assessed to a1oid "om+li"ations su"h as a"ute renal failure in
future, +ost o+erati1ely/ &oagulation +rofile must also #e assessed as she is s"heduled for surgery
and the surgeon must "onfirm that she does not ha1e any "oagulo+athy to a1oid from
"om+li"ations su"h as #leeding/
Diagnosis of hy+erthyroidism is usually straightfor-ard/ 5he +atient is euthyroid, the
nodules are +al+a#le and often 1isi#le 3smooth, usually firm and not hard4 and the goitre is
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+ainless and mo1es freely on s-allo-ing/ *ardness and irregularity, due to "al"ifi"ation, may
simulate "ar"inoma/ A +ainful nodule or the sudden a++earan"e or ra+id enlargement of a nodule
raises sus+i"ion of "ar"inoma> ho-e1er, su"h "ases are usually due to haemorrhage into a sim+le
nodule/ Differential diagnosis from autoimmune thyroiditis may #e diffi"ult and the t-o
"onditions fre?uently "oexist/ My +atient -as euthyroid, her nodules -ere +al+a#le and firm,
+ainless, nodular and mo1ed -ith s-allo-ing/ 0t -as 1ery indi"ati1e of multinodular goiter
undeed/ 5he general -or' u+ to rea"h a diagnosis is as #elo-:
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26
Aong8term follo-8u+ studies of hy+erthyroidism sho- a slight in"rease in o1erall
mortality, -hi"h affe"ts all age grou+s, is not fully ex+lained and tends to o""ur in the first year
after diagnosis/ 5hereafter, the only long8term ris' of ade?uately treated hy+erthyroidism a++ears
to #e an in"reased ris' of osteo+orosis/ Patients -ith +ersistently su++ressed 5S* le1els ha1e an
in"reased li'elihood of de1elo+ing atrial fi#rillation -hi"h may +redis+ose to throm#oem#oli"
disease/
5hus, hy+erthyroidism should #e "orre"ted/ 5hree +ossi#ilities are a1aila#le: antithyroid
drugs, radioiodine and surgery/ 5hyroide"tomy should #e +erformed only in +atients -ho ha1e
+re1iously #een rendered euthyroid/ &on1entional +ra"ti"e is to sto+ the antithyroid drug %$8%6
days #efore o+eration and to gi1e +otassium iodide 36$ mg three times daily4, -hi"h redu"es the
1as"ularity of the gland/ Bhen thyroid fun"tion is a#normal the +atient should #e rendered
euthyroid/ 0ndi"ations for surgi"al inter1ention are:
The possibility of malignancy/ A history of ra+id gro-th, +ain, "er1i"al lym+hadeno+athy,
"hange in 1oi"e or +re1ious irradiation to the ne"' are -orrying features/ A +ositi1e or
sus+i"ious FNA ma'es surgery mandatory and surgery may #e ne"essary if dou#t +ersists
e1en in the +resen"e of a negati1e FNA 3es+e"ially if the +atient is "on"erned #y the false
negati1e rate4/
Pressure symptoms on the trachea or, more rarely, oesophagus/ 5he +ossi#ility of
retrosternal extension should #e ex"luded/
Cosmetic reasons/ A large goitre is often a "onsidera#le anxiety to the +atient e1en
though fun"tionally and anatomi"ally #enign/
5he o+eration should #e +erformed only #y ex+erien"ed surgeons to redu"e the "han"e of
"om+li"ations:
,arly +osto+erati1e #leeding "ausing tra"heal "om+ression and as+hyxia is a rare
emergen"y re?uiring immediate remo1al of all "li+s;sutures to allo- es"a+e of the
#lood;haematoma/
Aaryngeal ner1e +alsy o""urs in %C/ Do"al "ord mo1ement should #e "he"'ed
+reo+erati1ely/
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5ransient hy+o"al"aemia o""urs in u+ to %$C #ut -ith +ermanent hy+o+arathyroidism in
fe-er than %C/
<e"urrent hy+erthyroidism o""urs in %8(C -ithin % year, then %C +er year/
*y+othyroidism o""urs in a#out %$C of +atients -ithin % year, and this +er"entage
in"reases -ith time/ 0t is li'eliest if 5PO anti#odies are +ositi1e/ Automated "om+uter
thyroid registers -ith annual 5S* s"reening are used in some regions, and ha1e
demonstrated that a high +ro+ortion of +atients #e"ome hy+othyroid in the long term/
My +atient under-ent a total thyroide"tomy in the hos+ital and this de"ision -as made #y
the surgeon as there -as +resen"e of tra"heal "om+ression in her -hi"h had "aused SOB/ *en"e,
it -as a good "all #y the surgeon as he had to relie1e the SOB and this -as already an emergen"y
"ase/ Post o+erati1ely, she did de1elo+ some of the "om+li"ations as mentioned a#o1e as her left
laryngeal ner1e -as +reser1ed #ut her right laryngeal ner1e -as not/ 5hus, she has "hange in her
1oi"e -here no- it is "oarse and "an #arely #e heard/ *er +arathyroid gland -as +reser1ed #ut
she does ha1e slightly lo- "al"ium le1el +ost o+erati1ely as transient hy+o"al"aemia o""urs in u+
to %$C of +atients, as mentioned a#o1e/ Before the o+eration, foot +um+ and sto"'ings -ere
a++lied for her and +ost o+erati1ely, she had someho- gotten a large ul"er on her leg -hi"h
o""urred -hen they remo1ed the sto"'ings +ost surgery/ 5his is an unforeseen "om+li"ation in
her "ase/
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