PATIENT NAME: XXXXX SEX: FEMALE OCCUPATION: UNEMPLOYED MARITIAL STATUS: SINGLE ETHNIC GROUP: MALAY DATE OF ADMISSION:

2 OCTOBER 2011 DATE OF DISCHARGE: 4 OCTOBER 2011 HISTORY TAKEN FROM: PATIENT

1. CHIEF COMPLAINT(S) Miss XXXXXX, a 27 years old Malay lady was admitted to admitted to XXXXX with presenting complaint of lump on the right neck for 9 months. 2. HISTORY OF PRESENTING ILLNESS She first noticed the lump on the neck 9 months ago (January 2011) unintentionally, when she looked in the mirror right after she undergo appedicectomy. That time it was small and painless so she did not seek for medical help. The lump was ovoid and in the right anterior neck. She done stated that he had done twice aspiration of fluid on the neck but the lump recurred. She went to Surgical Outpatient Department at Daily Care Complex, Kuala Terengganu at about 2 months prior to this admission for medical checkup. On checkup the lump on the neck is approximately 3 cm and fine needle aspiration cytology (FNAC) was done to investigate the histological features of the lump. She chose to undergo hemithyroidectomy because she is not keen for repeated aspiration. 3. PAST MEDICAL HISTORY She had been hospitalized before for acute appendicitis. 4. DRUG HISTORY She did not take any forms of supplement, drugs or traditional medication. 5. ALLERGY HISTORY There was no known allergy to any type of food or drugs

6. FAMILY HISTORY Her grandmother also had a lump on the neck which she describes extends retrosternally. But her grandmother never seeks medical help. No history of cancer in family. 7. SOCIAL HISTORY This patient is single and unemployed.

8. SYSTEMIC REVIEW CENTRAL NERVOUS SYSTEM She never had loss of consciousness or fit. However she did complain of episodes of headache. She had palpitations but no pain in chest She complained of shortness of breath probably due to secondary obstruction, no cough, no haemoptysis and no pain in chest. There was no altered bowel habit I.e. neither constipation nor diarrhea. She never had any episode of abdominal pain. There was no change infrequency and volume of urination. She did not experience dysuria. She did not have any episode of joint pain, joint swelling and backache. She did not have any skin rashes, eczema or pruritus. Menses regular and there is no experience of heavy menses.

CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM

GASTROENTESTINAL SYSTEM

GENITOURINARY SYSTEM MASCULOSKELETAL SYSTEM SKIN Reproductive System

9. PHYSICAL EXAMINATION A. GENERAL CONDITION AND VITAL SIGNS This is a medium built Malay lady lying supine comfortably on bed. She was pink, conscious, alert and oriented to time, place and person. She was not in pain and not in respiratory distress. There is no sign of jaundice and central or peripheral cyanosis. There were no stigmata of liver disease such as palmar erthema, leuconychia and no sign of finger clubbing. She is currently on IV drip.

B. VITAL SIGNS I. II. III. IV. V. Blood Pressure Pulse Rate Respiratory Rate Temperature Pain Score : 90/60 mm Hg : 81 beats per minute : 21 breaths per minute : 37 C : 0/10

C. HEAD AND NECK EXAMINATION INSPECTION Swallowing Tongue protruding PALPATION Margin Size Mobility Fixity Temperature Pulasatile PERCUSSION Over the sternum

Lump moved upwards with swallowing Lump did not move while tongue is protruding out and back in

Upper and lower margin are reachable They are regular 2 cm x 2 cm Mobile Not fixed to skin Temperature is normal Non-pulsatiole

Resonance over sternum which shows no retrosternal extension of thyroid occur.

AUSCULTATION On Lump

On auscultation, no thyroid bruit is heard.

10. CLINICAL SUMMARY 11. PROVISIONAL DIAGNOSIS My provisional diagnosis is thyroid cyst. The points or evidences that may support my diagnosis are from the history taking and physical examinations A) History Taking From history taking, malignancy thyroid is not likely in this case as he did not experience loss of appetite and loss of weight. Patient present with no pain suggest that it is not

inflammatory or anaplastic in origin. She has undergone aspiration twice before suggesting the lump is fluid filled (cystic). B) Physical Examination From examination she is non-cachexic. On palpation the mass was non-tender and soft. Soft consistency shows that the lump is most likely fluid-filled.

12. DIFFERENTIAL DIAGNOSIS A) Multinodular Goitre Multinodular goiter because of its non-tenderness and smooth surface. Although Multinoudlar goiter is of multiple nodular however usually only one nodule is palpable (dominant). Consistency of multinodular goiter also may feel soft. I cannot rule out this disease as patient shows signs of hyperthyroidism. B) Dermoid Cyst Dermoid cyst, because of its soft consistency on palpation. C) Lipoma Lipoma is also common on the neck and usually non-tender. Surface feels smooth. Color of skin overlying is of normal temperature. It is soft on palpation. 13. INVESTIGATIONS GENERAL INVESTIGATIONS A. FULL BLOOD COUNT WBC RBC RBC DISTRIBUTION WIDTH Haemoglobin Haematocrit Mean Cell Hb (MCH) Mean Cell Volume (MCV) MCHC Platelet Mean Platelet Volume

6.3 4.57 11.1 13.9 0.384 30.3 84 36.1 348 6.6

Automated differential NEUTROPHIL % LYMPHOCYTES % MONOCYTES % EOSINOPHILS % BASOPHILS %

51.4 38.8 5.95 3.69 0.112

B. BLOOD UREA SERUM ELECTROLYTE (BUSE) Urea Na+ K+ Creatinine 3.9 mmol/L 135 mmol/L 3.8 mmol/L 50 mol/L

14. SPECIFIC INVESTIGATION A) RADIOLOGY i) Ultrasound To differentiate cystic or solid nodule. Size assessment. ii) Scintillation (Radioisotope Scan) B) BIOCHEMICAL TEST iii) Thyroid Function Test Done and results came back as normal C) BIOPSY i) Fine Needle Aspiration Cytology Results came back as thyroid cyst.

15. OPERATIVE FINDING Normal Anatomy of Thyroid Thyroid is a gland located in the anterior neck .It is highly vascular and brownish red in colour. The gland is on the level of fifth cervical to the first thoracic vertebrae. It is ensheated by the pretracheal layer of deep cervical fascia. It has 2 lobes, right lobe and left lobe connected by an isthmus. The weight of the gland varies; the average weight is 25 g but is larger in female and they may enlarge during menstruation and pregnancy. Both lobes are conical liked shaped. Their ascending apices diverge laterally to the level of the oblique lines on the laminae of the thyroid cartilage, and their bases are level with the fourth or fith tracheal cartilages. They are usually 5 cm long, 3cm transversely and 2cm anteroposteriorly. Lateral Thyroid ligament fixed the posteromedial aspect of the lobes to the side of cricoids cartilage. A conical pyramidal lobe often ascends towards hyoid bone from the isthmus or the adjacent part of either lobe. This gland is supplied by superior and inferior thyroid arteries. They lie between the fibrous capsule and loose fascial sheath. The superior thyroid artery is usually the first branch of external carotid artery and it descends to the superior poles of the gland, piercing the pretracheal layer of deep cervical fascia and then divides into anterior and posterior branches supplying mainly the anterosuperior aspect of the gland. The inferior thyroid arteries are the largest branches of the thyrocervical trunks originating from subclavian arteries. They run superomedially posteror to carotid sheath to reach posterior aspect of the thyroid gland. They supply posteroinferior aspect of the gland which includes the inferior poles

of the gland. Within the gland, extensive anastomoses between superior thyroid areteries and inferior thyroid arteries ensure supply of blood while providing potentiall collateral circulation between subclavian and external carotid artery. Thyroid Ima artery may be present in certain individual in approximately 10% of population. It arises from the brachiocephalic trunk but maybe arise from the arch of aorta or from the right common carotid, subclavian, or internal thoracic arteries. When present it ascends on the anterior surface of the trachea, supplying small branches to it. Then it continues to the isthmus where it devides and supplies it. The superior thyroid veins accompany the superior thyroid arteries and drain the superior poles of the thyroid gland. While the middle thyroid veins do not accompany but run essentially parallel courses with the inferior thyroid arteries and drain the middle part of the lobes. Both veins will then drain into the Internal Jugular Veins. Inferior thyroid veins drain inferior poles which eventually drain into brachiocephalic veins posterior to the manubrium. The lymphatic vessels of the thyroid gland run in the interlobular connective tissue, usually near the arteries; they communicate with a capsular network of lymphatic vessels. From here, lymphatic vessels pass initially to prelaryngeal, pretracheal, and paratracheal lymph nodes. The nerves which innervate the thyroid gland are vasomotor not secretomotor, they cause vasonstriction of blood vessels. Endocrine secretion from the gland is hormonally regulated. These nerves derived from superior, middle and inferior cervical (sympathetic) ganglia which reach the gland through the cardiac and superior and inferior thyroid periarterial plexus that accompany thyroid arteries.

Anatomical Consideration during Operation Recurrent laryngeal nerve Recurrent laryngeal nerve is branch of vagus nerve. It supplies motor function and sensation to the larynx (voice box). It is called recurrent as it descends into the thorax before rising up between the trachea and esophagus to reach the neck. The longer Left recurrent laryngeal nerve, , branches from the vagus nerve to loop under the arch of the aorta, posterior to the ligamentum arteriosum before ascending. While the right branch loops around the right subclavian artery. As the recurrent nerve hooks around the subclavian artery or aorta, it gives off several cardiac filaments to the deep part of the cardiac plexus. As it ascends in the neck it gives off branches, more numerous on the left than on the right side, to the mucous membrane and muscular coat of the oesophagus; branches to the mucous membrane and muscular fibers of the trachea; and some pharyngeal filaments to the superior pharyngeal constrictor muscle.

The nerve splits into anterior and posterior rami before supplying muscles in the voice box it supplies all laryngeal muscles except for the cricothyroid, which is innervated by the external branch of the superior laryngeal nerve. The recurrent laryngeal nerve enters the pharynx, along with the inferior laryngeal artery and inferior laryngeal vein, below the inferior constrictor muscle to innervate the Intrinsic Muscles of the larynx responsible for controlling the movements of the vocal folds. In any thyroidectomy recurrent laryngeal nerve is prone to damage during the ligature of the inferior thyroid artery because of its proximity. Unilateral, the patient may present with voice changes including hoarseness. Bilateral nerve damage can result in breathing difficulties and aphonia, the inability to speak. The right recurrent laryngeal nerve is more susceptible to damage during thyroid surgery due to its relatively medial location.

Parathroid Gland Parathyroid gland is located posterior to the thyroid gland. Accidental removal of the parathyroid may cause decrement of parathyroid hormone which is responsible in blood calcium regulation. This may lead to hypocalcaemia which is very dangerous as it may cause tetanus and affects the heart contraction.

Operation Procedure and Finding A) Preoperative Checklist 1. Consent 2. Vocal Cord Assessment Indirect or direct laryngoscope is done to demonstrate vocal cord function. It evaluates preoperative recurrent laryngeal nerve function should there later be a question of operative damage. 3. Preoperative order 4. Preoperative result view 5. Removal of cosmetic view 6. Removal of jewellery 7. Nil orally 8. Preoperative imaging 9. Review patient vital signs 10. Preoperative bowel preparation 11. Patient emptied bladder

B) Intraoperative procedure Hemithyroidectomy 1. Collar incision in lines of skin tension 2 cm above suprasternal notch. Platysma divide in same line. 2. Flaps mobilized beneath platysma down to suprasternal notch and up to the thyroid cartilage. 3. Incision made vertically in midline between strap muscles which are retracted laterally on side of interest 4. Dissection continued deep to strap muscle. Midline thyroid vein ligated and divided. 5. Upper pole vessels identified and ligated close to the gland. 6. Lower pole vessels ligated. 7. Lateral lobe displaced anteriorly; inferior thyroid artery located and recurrent laryngeal nerve identified close to inferior thyroid artery. Inferior thyroid artery ligated lateral to nerve. Parathyroids identified. 8. Right lobe of thyroid is excised, carefully preserving recurrent laryngeal nerve and parathyroids. C) Postoperative procedure 1. Keep nil by mouth till fully conscious 2. Keep vital sign stable 3. Intravenous drip 4. Analgesic given (IV Tromadol) 5. Prop up patient to 30 6. Drain chart I/O chart 16. PLAN OF TREATMENT ON DISCHARGE After operation patients blood calcium level is monitored. One of the complications of thyroidectomy is removal of parathyroid which may cause hypocalcaemia. Watch for Chvostek sign (also Weiss sign (signs of tetany seen in hypocalcemia). It refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw. (masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia with resultant hyperexcitability of nerves. This patient post-operative calcium level is 2.02 and Chvostek sign is negative. Watch out for hoarseness of voice which may be complication of this surgery in which the recurrent laryngeal nerve maybe damaged intraoperatively.

Midazolam is prescribed as post-operative anti-emmitic and IV tramadol is given as analgesic. Voltaren and calcium lactate is prescribed on discharge for analgesic, anti-inflammatory and as calcium supply to body.

17. CASE DISCUSSION My patient, Miss XXXX a 27 years old Malay women was diagnosed to have recurrent thyroid cyst. Thyroid cysts are basically benign. Under benign classification of thyroid disease, there are thyroid adenoma, thyroid cyst, dermoid cyst, lipoma, haemangioma and teratomas.

18. FINAL DIAGNOSIS My final diagnosis is Recurrent Thyroid Cyst. 19. PATIENTS DISCHARGE SUMMARY (DISCHARGED ON 4th OCTOBER 2011) Upon discharge patient look well and comfortable. The wound is clean and no discharge seen. She was discharged.