Namaste,

I am Dr. Achyut Sharma, Anesthesia Resident in Bir Hospital.

I heard that you have a problem for which you need to be operated on. I am supposed to be
in the team of anesthesia for your operation. I have come here to enquire about your
problem and some other issues that may have impact during the surgical procedure.
I will enquire you about your problems, please answer me whatever you know. I may also
have to examine you after knowing about your problem.
During the questioning and subsequent examination, I will do my best to make you
comfortable. However, if at any time, you feel uncomfortable, please let me know.

So, do you have anything that you want to ask me before we proceed?

Thank you.

Shall we begin? _________. Thank you.

So, your name is ?_______________ (Dr. Kiran K.C.).

You are from ? ____________ (Butwal).
Married?
Religion?
Age?

So, Dr. Kiran, what brings you to this hospital?

I have a swelling in front of my neck.
Any other problem, beside this? No.

Can you describe me about the swelling?

When did you first notice the swelling? (A slowly progressive lump)
How was the onset of the swelling?
Any growth or changes in the swelling?
Does the swelling come and go?
Any change in the overlying skin color?
Did you have similar swelling previously?
Do you have pain over the swelling?

Do you have any other problems associated with the swelling like.
1. weight gain or loss?
2. difficulty in swallowing food?
3. difficulty in taking breaths? or breathing while lying flat?
4. noisy breathing?
5. hoarseness?
6. Hemoptysis (d/t intratracheal extension)
7. noticed any swelling of face or neck veins at any time?
Do you have?
- anxiety? palpitation? tremor? heat or cold intolerance? get easily fatigued?
diarrhea or constipation?
Have you ever gotten any treatment for the swelling? If yes, type?
Are you regularly taking the medication? Have you ever had the dose of the medication
increase?
Is the medication causing you any problem?

Review of Systems (ROS):

Do you have any other problems like?
- cough with sputum, feel SOB when walking up the stairs? chest pain? fever?
- Do you have problems lying flat due to SOB?
- Do you have to get up in the middle of the night feeling SOB?
- Do you have any problems of sudden LOC or sudden development of weakness of a
part of body, sudden jerky movement?
- Do you have any problems regarding urination?
- Do you have abdominal pain? nausea or vomiting?
- Do you have any musculoskeletal problems?

Past History:
Did you have similar problem in the past?
Did you have any other problem which required long term hospitalization or medication in
the past?
Do you have DM, HTN, or PTB in the past?
Did you ever have to get any surgery done on you? What kind? When was it done? Did you
have to get unconscious for that? Did the doctor tell you that you had any problems during
or after the operation? Did you regain your consciousness on time?
Have any other member in your family undergone any surgery?

Family History
Does any other member of your family have similar problem?
Is any member of your family HTN, DM or had PTB or any other cardiac disease or thyroid
disease?

Personal History
Do you smoke? Since when? How many sticks/packs per day?
Do you drink alcohol? Since when? How much?

Allergies and other relevant history

Do you have allergies to anything? like Drugs/food?
Did you have burn on any parts of body?
Do you have bleeding gums/mucosa?
Do you feel dizzy or get nauseated or vomit while travelling in vehicles?
If you are allowed climb stairs at your own pace, how many flights of stairs can you climb
before you get SOB?
Do you have any pain right now?
Do you have loose teeth? or dentures?

Is there anything else that you would like to tell me because you feel that is important but
I havent asked you?

PHYSICAL EXAMINATION
Dr. Kiran, you have really been a very good patient and I thank you very much for answering
my questions.
Now, that I know what the main problem is , I have to examine you very quickly and gently
to be able to correlate my findings and reach to a conclusion or decide what tests I may need
to do on you.
This shouldnt be very painful at all and at any time you feel uncomfortable, please let me
know. During this process, I may have to selectively uncover some portion of body to be
examined.
I hope that is OK with you.

Thank you so much. So, shall we proceed?

General Examination
Pallor?
Icterus?
Lymphadenopathy?
Cyanosis?
Clubbing?
Edema?
Dehydration?

Look?
Orientation?

Vitals:
Pulse: (regular, good volume, no radio-radial delay)
BP: (sitting position, right/left arm)
RR: (regular, good depth)
Temperature: (right/left axilla)
SpO2: (room air)
Pain:

Airway examination?
On general inspection- no gross facial deformity, neck swelling (?) (anterior/posterior),
oral/nasal cavity seems to be OK and trachea seems to be central in location.

Nasal patency: B/L nasal patency present, no obvious deformity of nasal bones.
Mouth opening: 6 cm interincisor distance
Dentition: seems to be normal, no loose teeth, no dentures.
Tongue/MPG: Grade II
TMJ: mobility present B/L
Slux: >0
Neck: no tenderness over cervical spine, neck flexion and extension present
Beard: not present
Thyromental distance: 6 cm
Sternomental distance: >12 cm
Neck circumference:??

Spine Examination: Normal spinal curvature, no localized swelling/deformity, interspinous

spaces normal
Weight of the patient:
Venous status: Normal

Examination of thyroid:
1. Ask the patient to take sip of water notice movement with deglutition
2. Examination of thyroid:
a. Laheys method
b. Crilles method
c. Description of swelling.
i. site: left side of neck
ii. shape:
iii. size:
iv. consistency:
v. tenderness?
vi. fixation?
vii. skin color change?
viii. movement of lump?
ix. temperature of lump?
3. Elicitation of Pembertons sign
4. Elicitation of tremors of outstretched hands/protruded tongue.
5. Can you get under the swelling?
6. Listen over the swelling for bruit.

Systemic Examination
1. Respiratory system:
a. Inspection:
i. No gross deformity of chest, no visible scar marks, overlying skin
changes, B/L chest seem to be moving equally with respiration.
ii. Trachea seems to be in midline
b. Palpation:
i. Trachea feels central in position
ii. Chest expansion:
iii. Tactile vocal fremitus:
iv. Apex beat: localized at 5th ICS medial to the midclavicular line.
c. Percussion: Resonant note B/L in all areas anteroposteriorly.
d. Auscultation:
i. B/L vesicular breath sounds
ii. No added sounds heard
 Cardiovascular system:
e. Inspection:
i. Jugular vein pulsation?
ii. Apical impulse?
f. Palpation:
i. Apical beat:
ii. Thrill?
iii. Heave?
g. Percussion: Not done
h. Auscultation:
i. Over 4 auscultatory areas
2. Abdominal
3. CNS
a. HMF
b. CNs
c. Sensory/Motor
d. Reflexes
e. Plantars?

Counselling about procedure/plan:

Dr. K.C. I like to thank you for being so patient and allowing me to complete my
history and examination. Now, that I have examined you, there are few things I
like to share with you.
- You are probably going to have a surgery to get rid of the mass which
mostly likely have arose from thyroid gland.
- You seem to be in good state of health otherwise, thus there doesnt
seem to be any problem in undertaking you for the surgery.
- During the surgery, we will have to render you unconscious by the use of
medications which will be given once we open an IV on you.
- During the procedure we will also give you pain medications and
medication that help you not remember the surgical procedure (which
normally is a traumatic incident for all of us)
- There are also specific things which you might have to remember very
carefully:
o You know, smoking is not good. So, I request you to please quit
smoking if you can. There are special techniques and drugs which
help you achieve that also.
o Also even if you quit from now on, there are certainly good effects
on your surgery too.
 o Thyroid gland is a very vascular gland. Thus any surgery here will
cause some blood loss though we will be very careful. Thus, you
might have to request you to arrange at least some units of blood.
o We require your stomach to be empty of food at least:
6 hours for solid foods
4 hours for liquid
2 hours for clear fluid like water.
o And lastly, surgery is a stress. So, if you feel stressed at night and
have difficulty in falling asleep we have medications to help you
have a better sleep. So do let the nurses in the wards know that so
that we can help you.

- Dr. K.C. Do you have any questions/queries for me?

Presentation of case:
Respected Sir,
I present a case of 32 years Dr. K.C. who is currently an inpatient in our hospital and a
permanent resident of Butwal, married, hindu by religion, has chief complaints of anterior
neck swelling for the past 7 months.
K.C. was relatively in good state of health until 7 months back when he noticed a swelling on
the anterior aspect of his neck which had an insidious onset, gradual progression to a
present size of about 3 cm, non painful and not associated with any changes in the overlying
skin. The swelling moves with deglutition. There is no history of dyspnea, dysphagia or SOB
during lying down, stridor or hoarseness or presence of swelling of face or prominence of
neck veins.. He also doesnt give history of change in weight during this period. There is also
no history suggestive of change in bowel habits, palpitation or slowing of heart, easy
fatiguability, intolerances to heat or cold, and fever.

Investigations:
1. Hb, TC/DC, Platelets
2. Electrolytes/RBS
3. Urea/Creatinine
4. CXR, Neck Xray- AP/Lateral
5. ECG
6. TFT
7. Flow volume loop
8. Indirect laryngoscopy

Anesthetic Diagnosis:
32 year, Male, surgical diagnosis of carcinoma of thyroid, ASA physical status 1, with normal
spine, no anticipated difficult airway, and no difficult venous cannulation is planned for left
sided hemithyroidectomy under general anesthesia with RSI with cuffed ET tube intubation,
with muscle relaxation with multimodal analgesia.
Anesthetic concerns in this patient?
1. Airway:
a. Thyroid mass: compressing the larynx
b. Large tongue
c. Edematous airway
d. Thickened nape of neck (difficult extension)
2. Cardiovascular system:
a. CO: 30-50% (decr HR, decrease contractility)
b. PVR: due to relative deficiency of T3 (which is a vasodilator)
c. Systolic/diastolic dysfunction: failure
d. Baroreceptor reflex: blunted
e. Elevated cholesterol: in long standing hypothyroidism (leading to
pseudohyponatremia and abnormal coagulation parameters)
3. Respiratory:
a. Blunted hypoxic/hypercapnic respiratory drive.
b. Drug induced respiratory depression
c. Risk of atelectasis (d/t weak respiratory muscles and surfactant level)
d. Risk of sleep apnea
4. CNS:
a. Exaggerated depressant effect of drugs on CNS