Chapter V

CASE STUDY PROPER

GENERAL DATA
Admission No.: IN-102016-0134568
Name:Patient X
Age: 29 years old
Sex: Female
Civil Status: Single
Occupation: Registered Nurse
Address: Brgy. 5 LucenaCity, Quezon
Religion: Born Again
Nationality: Filipino
Place of Birth: San Narciso Quezon
Birthday: January 9, 1987
Department: Surgery
Fathers Name:
Mothers Name:
Admitting clerk: Icado, Erren Lester Marty
Attending Dr.: Tang, Durvin William Jeff R N
Admitting Dr.: Carmona, Ramon Veloro
Date of Admission: October 24, 2016 Admission Time:
10:30 AM
Chief Complaint: With mass on neck left side
Admitting diagnosis: Nodular non-toxic goiter left
Final diagnosis: Nodular non-toxic goiter S/P left thyroid lobectomy under general anesthesia
Date of Discharge: October 27, 2016
AREA OF ASSESSMENT FINDINGS INTERPRETATION
HEADPhysical AssessmentNo wounds noted Normal
With dry and black hair
Normocephalic
EYES With positive pupillary reflex Normal
With equal pupil noted
No periorbital edema noted
With whitish sclera and pinkish conjunctiva

EARS With no lesions noted Normal

No ear discharges noted
NOSE No nasal discharges noted Normal
MOUTH With moist and pinkish lips Normal

NECK With sutured wound on neck Post OP day 1

With dry and intact dressing
With penrose drain

CHEST With symmetrical chest wall expansion upon Normal

respiration
With normal breath sounds heard on both lung
fields upon auscultation

ABDOMEN With non-tender abdomen upon palpation Normal

With positive bowel sounds heard upon
auscultation

EXTREMITIES No lesions noted Normal

No edema on both extremities
NAILS With pinkish nail beds Normal
With capillary refill time of 2-3 seconds upon
blanching
SKIN With good skin turgor Normal
History of Present Illness
Days prior to admission, the patient have seen a
noticeable lump on the left side of her neck, she
then touched it and palpated a mass. She has
tried looking at the lump as she was drinking and
it was moving in sync to the movement of her
swallowing. The mass progresses to cause a
difficulty while eating.Due to her anxiety because
of the mass, she consulted a physician, undergoes
in different laboratory examinations, and was told
that the mass was a cyst and is non-toxic.
Past Medical History
Before the development of cyst on the left
side of the neck, the patient has previously
had a cyst on the right side of her neck for
almost 3 years. She has received a treatment
for it through medications but did not
undergo in any surgical procedures since the
cyst was not causing any disturbance to the
patient.
Family Health History
According to the patient, they have a
family history of developing a cyst, her mother
also had a goiter in the past, other than that
they have no other possible hereditary
diseases that can be passed.
Laboratory Analysis
CHEST X-RAY (October 24, 2016)
Both lungs are clear.
Heart is not enlarged.
Diaphragm and sinuses are intact.

IMPRESSION:
ESSENTIALLY NORMAL CHEST FINDINGS.
 HEMATOLOGY (October 25, 2016)
RESULTS REFERENCE RANGE

HEMOGLOBIN MALE: 14-18 mg/dl

12.5 FEMALE:E 12-15 mg/dl
NEONATES: 14.5-55.5 mg/dl
HEMATOCRIT MALE: 40-50 vol%
40.1
FEMALE: 30-40 vol%
NEONATES: 45-75 vol%
WBC COUNT 8,800 5,000-10,000/ cumm
DIFFERENTIAL COUNT:
NEUTROPHIL 67 50-60%
LYMPHOCYTE 33 35-45%
MONOCYTE 2-4%
EOSINOPHIL 2-5%
BASOPHIL 0-1%

PLATELET COUNT 284, 000 ADULT: 150-540 x 10 g/L

NEONATE: 150-550 x 10 g/L
ULTRASOUND (THYROID)(July 22 2016)

The right lobe of the thyroid gland measures 4.9 x 0.6 x 1.8 cm. while the
left side lobe of the thyroid measures 6.4 x 3.1 x 4.0 cm There are hypo
echoic masses in the right lobe measuring 0.3 x 0.2 c and 0.5 x 0.3 cm in
size and a cystic mass in the left measuring 4.5 x 2.9 cm with intraluminal
echoes.

IMPRESSION:
CONSIDER ADENOMA, RIGHT.
COLLOID CYST, LEFT.
THYROXINE (T4) TRIIODOTHYRONINE (T3) AND TSH LEVELS(July 22 2016)

TEST RESULT INTERPRETATION REF. RANGE

Total T3 0.89 mg/dl Normal 0.58-1.59

Total T4 6.57 ug/dL Normal 4.87-11.72

TSH 0.4080 uIU/mL Normal 0.35-4.94

 Pathophysiology
NON TOXIC NODULAR GOITER

Course in the Ward

Day 1, October 24, 2016

On October 24, 2016, 10:30 am, Patient X, 29 y/o, female, single,
was admitted by Dr. Carmona in surgery ward. The attending
physician ordered to secure consent for the surgery, specifically
thyroid lobectomy for the following day, October 25, 2016, 06:00
am. Patient was seen and examined history of disease. He also
ordered for NPO diet post midnight, notify OR and
anaesthesiologist for clearance, notify SROD, refer accordingly.
Medications; Omeprazole 40 mg, TIV OD x NPO, Ordansetron 4 mg,
TIV PTOR given. Patient placed on NPO at 10:0 pm, Dr. Carmona
ordered IVF of D5LR 1Lx8 hrs once on NPO.

Day 2, October 25, 2016
Status post thyroid lobectomy left under general anaesthesia.
Maintain oxygen saturation greater than or equal to 94. Place patient into
moderate to high back rest. Diet as tolerated with strict aspiration
precaution once fully awake. Regulate IVF to 30gtts/min consumed, then
disconnect. IV to follow; first up to third bottle of D5LR x8hrs. Dr. Carmona
ordered medications such as: Ceftriaxone 1gm IV after negative sensitivity
test q12, Hydrocortisone with loading dose then 100 mg IV q8, 3 dose-load
done at 7:05 AM, Tranexamic Acid 500 mg IV q8 for 3 doses, loading dose
given at 07:05 AM, Paracetamol 500 mg IV q6 for 4 doses, Mefenamic acid
500 mg/capPO TID for pain when full stomach. Vital signs q15, monitor
until stable.Watch out for difficulty of breathing, cyanosis, hoarness of
voice,muscle weakness, and other untoward signs and symptoms.
Mupirocin ointment apply on affected area three to four times a day. Refer
accordingly.
 Day 3, October 26, 2016
Diet as tolerated when fully awake. Continue
management. Daily wound care. Monitor VS ever
four hours then refer.
Day 4, October 27, 2016
With text order from Dr. Carmona; with may
go home order. Home medications given such as:
Co-Amoxiclav 625 mg two times a day, Celecoxib
200 mg two times a day, Mupirocin ointment to
surgical site two times a day daily.
 EVALUATION
After reviewing the case of Patient X which is
about Non Toxic Nodular Goiter, the students can
now differentiate the possible and realistic signs
and symptoms that may occur to that patient`s
condition. While conducting a group case study
presentation, the students hadreviewed the
pathophysiology to be able to understand and
correlate it to it`s general theory.