A Goitre.docx

KAMPALA INTERNATIONAL UNIVERSITY Western campus

NAME: MOREBU PETER MOMANYI

REG NO: BMS/0018/71/DF

CLASS: 4.3

FACULTY: FACULTY OF CLINICAL MEDICINE AND DENTISTRY.

DEPARTMENT: SURGERY.

FACILITATORS: Mr.Wachaya. Mr.Shaaban. .

Mr.Kizza. Mr.Tumusiime. Mr.Okumu.

DATE:

BIODATA NAME: Mayanga Rose AGE: 58yrs SEX: Female TRIBE: Sabi RELIGION: Masiah ADDRESS: Palisa EDUCATION LEVEL: S4 MARITAL STATUS: Married NEXT OF KIN: Noweglo Claire (daughter) D.O.A: 31/10/10 D.O.D: 06/11/10

PRESENTING COMPLAINT -

Neck swelling for more than 10 years.

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Chest pain for about 1 year.

HISTORY OF PRESENTING COMPLAINT Rose was apparently well until about ten years ago when a swelling in the neck was noticed by her friends and family. She herself did not feel the swelling. The swelling was of gradual on set and painless, it would sometimes shrink and almost disappear then reappear.

Then about a year ago, she developed dull pain in the chest, which was of fairly sudden onset and intermittent. She also reports that the pain felt like a heart burn and appeared to be caused by the neck swelling. The pain was occasionally associated with difficulty in breathing, especially when lying on her back, and perceptible pulsation of the heart or increased in frequency and/or force of the heart, especially when doing some work and therefore she rests most of the time. This pain was aggravated by eating, especially matoke and beans, which she has since stopped eating and relieved by drinking cool water hence she drinks a lot of water. The patient also reports that the pain is often accompanied with a feeling of a heavy mass in the chest and the pain has no radiation and is constant.

The patient reports no history of tremors, increase or decrease of weight, no changes in her appetite, or voice, and no heat or cold intolerance.

The patient once went to Nsambya Hospital, in Kampala, with the swelling as her primary complaint where Iodine and Thyroxine tablets were prescribed for her, this helped a little as she reports. In addition, she also went to a clinic in Palisa, where she was given Magnesium to relieve the pain. This only helped temporarily. Since all her efforts were in vein, she opt not to bother herself with the swelling until she learnt of the services offered here.

REVIEW OF OTHER SYSTEMS -

Central nervous system - No history of confusion, headache, convulsions, mental lethargy, emotional lability and blurring of vision.

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Genital urinary system - Passes urine more frequently because she takes a lot of water. The urine is normal in color and no pain upon passing urine. She has no

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Gastrointestinal system - Complains of constipation and slight abdominal distention there is no loss of, or increased, appetite, no nausea, no diarrhea and no vomiting.

PAST SURGICAL HISTORY She has no history of any surgical operations performed on her, no history of trauma and has not had any blood transfusions or burns.

PAST MEDICAL HISTORY This is her index admission; she has no known chronic illnesses, no food and drug allergies. Her HIV serostatus is non-reactive.

OBSTETRIC AND GYANECOLOGICAL HISTORY She is a para 7+0, she attended antenatal clinics, and all deliveries were carried to term normal and by spontaneous vaginal delivery. She has no history of abortions, ectopic pregnancy, gynaecological surgery (hysterotomy, D & C) or gynaecological procedures (PAP smear, mammography) carried on her. Menarche was at 16 years and she now is post menopausal.

FAMILY AND SOCIAL HISTORY She is the 4th born in a family of 5 (3 sisters and 2 brothers). One of her brothers is died due to malaria, there’s no history of chronic illnesses that run throught the family like diabetis mellitus, hypertension and sickle cell. She is married with 7 children (1 boy and 6 girls) all are alive and well, the husband is also alive. They live in a permanent house and get water from a pump which they don’t boil for drinking. They sleep under mosquito nets.

SUMMARY Mayanga Rose, a 58 year old female who presented with a painless neck swelling for ten years and one year history of sudden onset of burning chest pain associated with palpitations and difficulty in breathing.

PHYSICAL EXAMINATION General Elderly woman of good nutritional status, afebrile with axillary temperature of 36.5 degrees celcius, calm and in no obvious distress, with no jaundice, palor, dehydration, oedema, cyanosis no lymphadenopathy.

Local On inspection, there is a swelling on the anterior lower left side of the neck. The swelling moves freely on swallowing but does not move upon protruding the tongue. On palpation, there are no nodules, the temperature is the same as of the surrounding and no tenderness was elicited. The swelling is approximately 7cm x 5cm x 4cm and there are no bruits on auscultation.

Systemic Examination Respiratory system Inspection - Chest moves symmetrically upon respiration, the respiratory Rate is 28 c/m, there are signs of distress. The trachea is centrally placed. There are therapeutic scars seen. Palpation - No tenderness elicited. Tactile fremitus normal. Percussion - Chest resonant to percussion. Auscultation- Normal breath sounds heard. Chest is clear with no bruits.

Per abdomen Inspection - The abdomen is of normal fullness with a centrally placed inverted umbilicus. Moves with respiration, has no scars and no dilated veins. Palpation - There are no areas of tenderness or masses felt nor was there any organomegalies. Percussion - The abdomen was of resonant note. Auscultation - Normal bowel sounds present.

Cardiovascular System There was full volume with regular pulse. No hyperactive pericardium. The heart sounds were heard and normal. No murmurs heard/ bruits. Vitals: BP 162/99, Pulse 80 b/min.

Central Nervous System The patient was fully conscious, alert, well oriented in time, place and person. GCS score was 15/15 with no neurological deficits. The patient’s speech is normal (not sluggish).

Musculo-Skeletal System On inspection there are no swellings of any kind in joints and muscles, no deformities are noted, and there is no colour change on the skin over joints. On palpation there is no tenderness. On movement the muscle power and tone are normal, the patient has no slow movement, and there is no crepitation.

IMPRESSION Simple goitre.

Differentials -

Thyroid carcinoma

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Autoimmune thyroiditis

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Cervical adenitis/abscess

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Cysts e.g. Thyroglossal duct cyst, dermoids cyst, brachial cyst.

PLAN -

Admit to surgical ward

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Counsel patient, obtain consent and prepare for thyroidectomy

Investigations -

Thyroid function test ( done )

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Chest and thoracic inlet X ray (done)

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Complete blood count (not done)

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Grouping and cross matching (done)

FOLLOW UP Day one - Pre operatively Thyroid function test results were obtained and were in the normal range, therefore euthyroid. Cervical x-ray showed soft tissue, calcification in the gland , and slight compression of the trachea. The condition was explained to the patient and the procedure to be carried out on her, the advantages and its risks were also explained. Consent was then obtained and signed. Anesthetist was called in to review the patient and deemed her fit for the operation. Vitals were also taken and were okey and fitting for the operation. Blood was taken off for grouping and cross matching, and two units of blood were booked.

Day two - Intra operatively Rose was resuscitated with adequately, put under general anesthesia and partial thyroidectomy was carried successful.

Post operatively Immediately Patient was transfused with 2 two pints of blood, antibiotics and analgesics were given. Intravenous fluids were also given, that is, 2 litres of dextrose and 1 litre of normal saline. Vitals were continuously monitored.

Day three Patient doing well, vitals normal, no new complaints, wound clean. Plan was to continue with the treatment.

Day four Patient doing well, vitals normal, no new complaints, wound clean. Plan was to continue with the treatment.

Day five Patient doing well, vitals normal, no new complaints, wound clean. Plan was to continue with the treatment

Day six Patient doing well, vitals normal, no new complaints, wound clean. Plan was to continue with the treatment

Day seven Patient doing well, vitals normal, no new complaints, wound clean. She request for discharge. Plan was to discharge her on treatment of amoxyl 500mg tds x 5/7, stitches to be removed on 08/11/10 and asked to come back for review after two weeks

DISCUSSION A goitre or goiter, is a swelling in the thyroid gland, which can lead to a swelling of the neck or larynx. Goitre usually occurs when the thyroid gland is not functioning properly. Goitres result from follicular cell hyperplasia at one or multiple sites within the thyroid gland. The mechanism is multifactorial; genetic, environmental, dietary, endocrine and other factors.

On the basis of clinical and pathological features goitres can be sub classified as follows; -

Epidemiologically; Endemic, sporadic and familial.

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Morphologically; Diffuse and nodular ( multinodular, solitary nodule)

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Thyroid function status; toxic and non toxic

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Location; cervical, retrosternal, intrathorasic.

The different etiologic mechanisms that can cause a goiter include the following: -

Physiological causes in conditions where thyroid hormones are greatly needed to meet the metabolic rates, Physiological demands are: Puberty, Menstruation, Pregnancy, lactation

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Pathological deficiency, reduction of thyroid hormones leads to hyper-stimulation of thyroid gland as the above, e.g. Lack of iodine in the diet, Deficiency of iodine absorption from the gut, Deficiency of enzymes necessary for oxidizing, Autoimmune thyroiditis, Goitrogens e.g. cabbages, Stimulation of TSH receptors by TSH from pituitary tumors, pituitary thyroid hormone resistance, gonadotropins, and/or thyroid-stimulating immunoglobulins, Inborn errors of metabolism causing defects in biosynthesis of thyroid hormones,Exposure to radiation e

The patient under discussion had a simple goitre which develops as a result of stimulation of the thyroid gland by thyroid stimulating hormone (TSH), its generally asymptomatic and usually present with a neck mass which may be diffuse or nodular in this case it was diffuse and euthyroid, compressive symptoms are also observed which include, dyspnoea due to tracheal displacement, dysphagia due to oesophageal compression, voice changes and distended neck veins. Pressure symptoms were also observed in the patient as were evident with Tachypnea, respiratory distress and a raised blood pressure. In simple goitre Partial Thyroidectomy – aims at removing the bulk of the gland, leaving up to 8gm of relatively tissue in each remnant + Thyroxine to suppress TSH secretion, with the aim of preventing recurrence. Indications for surgery include: -

Cosmesis

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Pressure symptoms

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Patient anxiety

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Retrosternal extension with actual or incipient tracheal compression

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Dominant area of enlargement that may be Neoplastic

In Rose’s case surgery was due to pressure symptoms, cosmesis and patient anxiety. The procedure was carried out successfully with no complications, which usually include -

Haemorrhage

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Respiratory obstruction - usually 2° to; anaesthetic complications, tension haematoma, Open sutures to release the haematoma, laryngeal oedema, tracheal collapse

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Parathyroid insufficiency (30%) - 2° to removal of the glands or infarction through damage to the parathyroid end artery

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Thyroid insufficiency - occurs within 2-5yrs

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Thyrotoxic crisis (storm)

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Wound infection - A subcutaneous or deep cervical abscess

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Recurrent laryngeal nerve paralysis - Transient paralysis occurs in 3% & recovers in 3wks3months; Leads to vocal cord paralysis with blockage of the upper airway especially if bilateral. I

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Stitch granuloma

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Hypertrophic or keloid scar - especially if the incision overlies the sternum.

REFERENCE 1. Bailey & Love Short Practice of Surgery. 2. Hutchison’s Clinical Methods 3. Tutorials