CRS : Neck Lump

PATIENT’S NAME [7U | ECS]

Ng Chai Hoon, 70y
Chinese lady
01376225

DATE OF ADMISSION

24th Jan 2018

SUMMARY HISTORY OF THE PATIENTS CONDITION

U/L

1. hypertension

2. toxic MNG

CC:
electively admitted for total thyroidectomy

HOPI:

Currently well, no hyperthyroidism sx

Electively admitted for total thyroidectomy

20yrs ago,

Dr informed that she has small neck lump over the left side during HPT f/up but not on any meds

2 yrs ago, the neck lumps started increasing in size (left side)

No pain, no skin changes

No obstructive sx - SOB, stridor, dysphagia, hoarseness of voice

She also notices hyperthyroidism sx for 2-3 months

-heat intolerance

-mild tremor

-palpitation

-LOW (10kg in 6 months)

-high BP (>150/90)

-diarrhea

Especially at night

So, she went for check-up and was started on oral CBZ

Sx resolved after the meds

2 months ago, she noted to have upper limb weakness, lethargy

Most probably due to dose adjustment from 20 ->10 ->5 mg / day -compliance to meds

Menopause since 40+y

No thyroid eye disease - no diplopia / VF defect

No FH of thyroid problems / cancer

No fever

No URTI sx

Not hx expose to radiation

NYHA class 3

Otherwise,

No chest pain, SOB

No headache, dizziness

No URTI / UTI sx

No HF sx
PMH:

1. HPT dx 20 yrs ago not on any meds at that time, just take starfruit

Jan 2017 -> was started on metoprolol 50 mg BD and amlodipine 5 mg OD

f/up -> every 2-3 months in PPUM

No DM or other disease

Past Surgical Hx:

Appendicectomy -1974

LSCS -1976

FH:

Father - colon cancer (died at age 55+)

No FH of thyroid disease

Social Hx:

She was a medical lab tech in PPUM

Live in PJ with husband, son and grandchild

ADL independent

Non-smoker

Occasional drinker

Allergy to crab -> vomiting, no rash

Meds:

NKDA
EXAMINATION OF ALL SYSTEMS

Alert, conscious
Speaking in full sentences
CRT < 2 sec
Good pulse volume
PR 80 bpm, regular rhythm

Warm peripheries
No thyroid acropathy
No fine tremor

No lid lag, no lid retraction

No exophthalmos, no diplopia

Neck -

No surgical scar, no skin changes

anterior neck swelling

Left large nodular lobe palpable, enlarged 4x5 cm

Smooth surface, regular border, firm in consistency

Able to feel the inferior border

Move with swallowing

Not move by tongue protruding out

Right lobe normal

[Clinically euthyroid]

Lungs - clear

Abd - soft, non-tender

VC assessment done - normal VCA

RELEVANT INVESTIGATION(S)

FBC-Normal

RP -Normal

ALP 135 high

PT / APTT normal

TFT

Free T4 9.7 low

TSH 1.18, Free T3 4.8 normal

US neck of 6 Apr 2017

-the right thyroid lobe is normal in size measuring 1.2 x 1.4 x 4.0 cm (AP x W x H) with 2 nodules seen
within measuring 0.7 x 0.7 x 1.0 cm and 0.3 x 0.4 x 0.6 cm respectively

-there is no increase in vascularity

-the left thyroid lobe is diffusely enlarged with no normal thyroid tissue seen measuring 3.2 x 4.9 cm x
7.5 cm

-no increases in vascularity noted

-there are multiple foci of calcifications within, the largest measuring 1.5 cm

-retrosternal extension of left thyroid lobe noted

-bilateral sub centimeter cervical LN with preserved fatty hilum present

CT neck contrast of 19 Dec 2017

-there is a large heterogenously enhancing mass arising from the left thyroid lobe measuring
approximately 4.8 (AP) x 5.3 (W) x 10.8 (Ht) cm

-scattered foci of calcifications noted within

-a calcified hypodense lesion noted in its superior aspect measuring approximately 1.5 x 1.1 cm in
keeping with cystic degeneration

-there is associated retrosternal extension extending down to T2/T3 vertebral level

-the lesion also displaced the trachea and oesophagus to right with narrowest tracheal diameter
measure 0.7 cm in T11 level

-the left internal jugular vein is compressed and narrowest, however it remains patent
DIAGNOSIS

Left thyroid lobe goiter with retrosternal extension and tracheal narrowing

OUTCOME / PROGRESS

Plan:
1- blood ix
2. pre op chest x ray and ecg
3. for op consent
4. keep NBM at 12 MN
5. once NBM, IVD 4 pints - 2 pints NS and 2 pints D5%

Pt underwent total thyroidectomy for toxic MNG goiter on 26/1/18

Intra-op findings; R 7g, L 210 g
Multinodular left thyroid lobe

Recurrent laryngeal nerve preserved bilaterally

L RLN positive 10nm signal but nerve not visualized
Bilateral superior and inferior parathyroid glands preserved

Currently
Comfortable, no numbness
Tolerating orally
No fever

Meds; T calcium carbonate 1g BD, T L-Thyroxine 100mcg OD

If pt presented with thyrotoxicosis,

Blood
1. TFT
2. glucose, HbA1c
3. lipid profile
4. RP
5. ABG
6. FBC - WCC

7. anti-TG, TG
8. ANA / AMA
Imaging

CXR
Neck Us
CT scan - trachea deviation + retrosternal extension
Radioisotope
- cold spot -> papillary / medullary
-hot spot -> malignancy <2%

Others

ECG
Urine ketone (if suspected DKA)
FNAC

US neck (suspected malignancy) if;

1. irregular margin
2. heterogenicity
3. hypervascularity
4. microcalcification

Bethesda classification for FNAC:

1. non-diagnostic
2. benign
3. undetermined, FLUS
4. follicular neoplasm - adenoma / carcinoma
5. suspected malignancy
6. malignancy - PTC / MTC

RX

1. surgery - hemi vs total

+/- central node dissection (between hyoid bone, carotid A, suprasternal notch)

2. radio iodine