DAHVINIA B.DEVAN

Name Siti Sanah

Age 46 years old

Race Malay

Address Tawau, Sabah

Date of admission

18/7/2007

Date of clerking

19/7/2007

Presented with anterior neck swelling for the past 12 years

She noticed the swelling 12 years ago while looking at herself in the mirror during her last pregnancy

At that time the swelling was as big as a 20 cents coin located at the anterior of her neck on the right side, after delivery the swelling persisted and over 12 years it gradually increased in size, currently as big as a

It was :

not painful there was no skin changes on the overlying skin no other swellings

Does not complain of obstructive symptoms such as:

shortness of breath difficulty in swallowing

However she had unintentional weight loss where she had lost 12

kilograms in the past 2 months

Her menstruation has been irregular for the last 2 years missing up till 3 months at times. And her menstruation bleeding lasts only for 2 days where she uses 2 pads per day, not fully soaked

Otherwise, she denied any hypo or hyperthyroid symptoms such as heat/cold intolerance, tremors, palpitation, anxiety, sleeping difficulties, irritability, frequent perspiration, muscle weakness, depression, lethargy, constipation or diarrhea.

No history of exposure to radiation previously or history of living in highlands

She does not have cough, bone aches/ history of fractures

She initially presented to Hospital Tawau early this year where an FNAC was done with results suggesting Papillary thyroid carcinoma, she was than referred to Putrajaya hosp for total thyroidectomy and further management

She has no known medical illnessNever been hospitalized for other reasons

besides child birth

She is not on any medicationDoes not use over the counter drugs or

traditional medicinesThere are no known drug allergiesShe is not allergic to any food

She is a divorcee living with 3 out of her 5 children ranging from 25 years old – 12 years old

She used to work as a laborer in a provisional store but has stopped working for the last 3 years as 2 of her children had started working

The 2 eldest children support her financiallyCurrently she stays at home and does chores

around the houseShe lives in a rented wooden house in tawauShe does not smoke and does not consume

alcohol. 

None of her family members suffers from a

similar condition.Her mother is wellher father passed away because of old ageNo family history of thyroid disorders or

malignancies

Normally consumes rice, and vegetables, occasionally fish

Uses normal salt that is being sold

SwellingLoss of weightHoarseness of voice

General examinationMy patient is sitting in bed. She is of average

built, She is conscious and orientated to time and

place.

She has no clubbing, no pallor, no jaundice no koilonychia, no onicholysis, her palms are moist and sweaty, there is no fine tremor, her skin is not dry

Vital signs :

No signs of pretibial edema Eyes no peripheral loss of eyebrows, conjungtiva

not injected, not pale, no exopthalmus,no lid retraction or lid lag

Temperature 37 ⁰C

Pulse 88 bpm

Blood pressure 140/90 mmhg

Respiratory 15 breaths per minute

Neck examination

Inspection: diffuse swelling at the anterior neck extending

from the posterior margin of the right sternocleidomastoideus muscle to the anterior border of the left sternoccleidomastoideus muscle , vertically and from the hyoid bone down to the sternal notch

It moves with deglutination and does not move with the protrusion of the tongue

The jugular vein is not distended and no dilated veins over the swelling

no surgical scarsno other skin changesNo other swelling seen

PalpationWarm, non tender, position of the trachea

cannot be appreciated irregular shape swelling measuring 22 x 15 cm

with smooth surface and firm consistency, well defined edge on the left side but not on the right side (irregular), moves with swallowing, mobile vertically and laterally, not attached to the overlying skin and or underlying structures, no fluctuance, not pulsatile, no thrill

the carotid pulse absent on left signno cervical or supraclavicle lymph nodes

palpable

PercussionThere is no retrosternal extension of the lumpAuscultationThere is no bruit heard Hoarseness of voice present

Condition Supporting

Thyroid Malignancy Increase in size, LOW, age, sex, hoarseness of voice, possible history of long standing goitre

Goitre Age, sex, diet, noticed during pregnancy

Inv results

Full blood count Hb: 11.5 Hematocrite 34.3 Platlet : 225 TWC: 6.1

TFT T4 3.23 pmol/L (9-24) (L)

TSH 29.20 (o.49-4.67) (H)

Random blood sugar 5.06 (n)

Liver function test NORMAL

Renal profile Urea 3.7 ; Na:139 ; k:1.9 ; creatinin:37

Coagulation profile INR: 1.145Ptt :27 (23-40) nPt : 12.7 (11-16)n

Inv results

Serum Calsium’ 2.23

Serum phosphate 1.31 (0.8-1.6) N

Neck Ct scan highly suggestive of cancer of thyroid with invasion to larynx including vocal cords and hypopharynx

Metastasis to cervical lymph nodes and bilateral lungs

Histopathology(biopsy)

Trucut biopsy suggestive of papillary thyroid cancer

ECG

Chest x-ray

Vocal cord assestment Right vocal cord – with 70 degrees scope-Rt vocal cord immobile on resp and phonation -Lf vocal cord mobile , gap present on phonationTRO rt vocal cord palsy

Advanced papillary thyroid carcinoma

History

PE

INV.-TFT -CTSCAN-biopsy

1. Monitor TFT2. Blood pressure monitoring3. To start patient on L.Thyroxine 100mcg OD4. Start patient on amlodipine 50mg 5. Lung function test6. Echocardiography7. Incentive spirometry for patient8. Total thyroidectomy planned for 28th July

20119. To repeat all blood investigations pre-op

Lung function test Normal ventilatory function

Echocardiography Ejection fraction 73%, with no LVH and mild MR

18/7/2011 27/7/2011 :

TFT showed fluctuating results ranging from T4 and TSH from L-thyroxin was started initially as patient was subclinically hypothyroid however withhold at certain periods where TFT showed normal or hyperthyroid.

Repeated blood examinations no significant difference

27th July 2011T3: 7.06 ( raised) TSH: 3.23 (N)

Plan1.Continue with the surgery2.NBM 6 hours prior to surgery3.Give anti-hypertensives + sips of clear fluid

on day of operation4.GXM 6 pints of blood, 2 point in OT and 4

standby in lab

Rt lobe of thyroid replaced by tumour

measuring 10 x 10Adherent to strap muscleRt IJV thrombosed with tumour weight of gland 668 gramRight carotid artery free from tumour, vagus

nerve preservedRight recurrent laryngeal nerve not seenRight parathyroid glands not seenTumour infiltrated trachea and shaved off

Left thyroid lobe normal Left superior parathyroid gland seen however inferior could

not be seen Strap muscle which has infiltrated by tumour was excised 2 drains was placed, left and right

Intra-op diagnosis : Advanced Follicular Thyroid Carcinoma

Intra –op v/s: 110-90/60-57 mmhg, 60-70 bpm, SpO2 97-98

Intra-op ABG: 7.33/44/122/-2.1/22.9/99.4%/lac 0.9CVP: 11-15Hb: 10.9 g/dl

Plan Pt sent to ICU intubated, on ventilator and sedated cont IV

midazolam, IV morphine 2mg/hourly

IV ranitidine 50 mg tdsIVD 2NS 2 DSIV IV ca gluconat 1 g tds 1/7Repeat blood examinations in ICU (FBC,

coagulation screeen, RP, ABG, serum calsium post op 6 hours than bd)

ECG stat in ICUi/o chartingDVT foot pumpExtubation cm

Completed 4 pints of packed cells Completed 2 unit of FFP

Phy examination:

Vital signs

Lungs clear, CVS DRNM

Bp 120/64 mmhg

Pulse rate 55 bpm

temperature afebrile

Drain

Significant inv results:

Hb: 11.2 (N)platlet 151 (N)Rp creat 42ca: 1.912.01 (L)inr/pt/aptt : 1.1/26/13.1 (N)

Drain amount

Right (functioning) 50 cc hemoserous

Left (functioning) 50 cc hemoserous

Plan2 units of FFPOnce tolerating orally start Ca. lactate 2 tabs

tdsCont VM post extubationFBC and Coagulation screen dailyEndocrine: plan to get RAI therapy date prior to

start of thyroxine therapy

ICU day 2Hb 11.5 g/dl, pt/aptt: 27/12.7 NOff cbd, ryles tube, of ivi morphineStart tab tramadol 50mg td + ca lactate 2tab tdsChest physioTrace TFT/alb(33)

ICU day 2 (evening)Extubated, change to CPAP ,pt comfortableHoarseness of voice>>>promientChanged to VM 50% cmabg 7.45/33/178/231/-0.2/99%,

lac 0.6Ca: 2.06 (L) add ca lactate 4 tab qid + alfacalcidol 1

mcg odrepeat ca cm (2.08)Start l.thyroxine 200 mcg odRAI date only in

SeptemberCont other medicationsAllowed to ward +incentive spirometry and chest physio

POD3-POD5

Pt v/s normal,ambulatingHoarseness of voice not worseningBp: 146/81 pr: 88No hypocalcemia symptoms Lungs clear, cvs DRNMWound clean, no hematoma drains

Chovstek sign (-)POD 3 Ca 2.08- on calsium gluconate IV tds and

ca. lactate 4 tab qid +alfacalcidolIV ca stopped and serum ca on POD4 : 2.10

drains amount

right 50 cc

left 30 cc

Pod 6-patient allowed for discharge,-remove drain-referral to Tawau hosp for follow up and

medication-tab L-thyroxine 200mcg od 2/12 -tab calsium lactate 300mg x 3 od 2/12-cap alfacalcidol 1 mcg od-amlodipine 5mg od 1/12-PCM 500mg x 2 qid 1/12

Management of differentiated thyroid cancer

Type findings

Pappillary Orphan annie, psamoma bodies

Follicular Follicles,Capsular/vascular invasion

Medullary Amyloid depositionIHC: calcitonin

Anaplastic pleomorphic giant tumor cell nuclei

Lymphoma Reed-sternberg cells,

Post thyroidectomy complications 1.Hypocalcemia2.Hypoparathyroidism3.Vocal cord dysfunction4.Recurrent laryngeal nerve injury5.Hematoma6.Haemorrhage7.Wound infection8.tracheostomy

AACE Clinical Practice Guidelines for the Diagnosis and management of Thyroid Nodules. Endocr Pract 1996;2:78-84.

Solomon BL, Wartofsky L, Burman KD. Current trends in the management of well-differentiated papillary thyroid carcinoma. J Clin Endocrinol Metab 1996;81:333-339.

Pyke CM, Hay ID, Goellner Jr, et al. Prognostic significance of calcitonin immunoreactivity, amyloid staining and flow cytometric DNA measurements in medullary thyroid carcinoma. Surgery 1991;110:964-970.

Bailey and love Surgery textbook