LBEN CASE
FOR LEARNING UNIT VI
ORL 251
Instructions: Accomplish the following tasks indicated in this case.
OPD SUBSPECIALTY CLINIC CONSULT: LBEN
S> VA 47F from Silang, Cavite
Chief Complaint:
anterior neck mass
History of Present Illness:
2 years PTA: Patient noted growth of an anterior neck mass, initially located slightly on the left
side of the neck, around 1.5 x 1.5 cm in size, non-painful, movable.
In the interim, there was noted gradual growth of anterior neck mass. No noted dyspnea,
dysphagia, odynophagia. No noted symptoms of fever, weight loss, palpitations, tremors, hair
loss, bowel movement changes were noted as well.
1 year PTA: Gradual growth of mass to present size, prompted PGH ORL consult where
diagnostic procedures were done.
Review of Systems:
ROS: (-) fever (-) dyspnea (-) headache (-) rhinorrhea
(-) cough (-) dysphagia (-) vertigo (-) anosmia
(-) colds (-) odynophagia (-) ear pain (-)nasal
(-) weight loss (-) hoarseness (-) dizziness congestion /
(-)heat (-) BOV obstruction
intolerance (-) malocclusion (-) diplopia
(-) hearing loss (-) trismus (-) otorrhea
(-) palpitation (-) otorrhagia
(-) tremors
Past Medical History:
(-) Hypertension (-) Bronchial asthma
(-) Diabetes mellitus (-) Allergies
(-) Pulmonary tuberculosis
Family Medical History:
(-) Hypertension (-) Bronchial asthma
(-) Diabetes mellitus (-) Allergies
(-) Pulmonary tuberculosis
(+) "goiter" - mother
Social History:
Non-smoker, non-alcoholic
Works as a housewife; no previous exposure to radiation
Lives in a 1-story bungalow house with her husband and daughter
O> On PE, the patient has the following findings: (description)
Ear: The pinna and external auditory canal were unremarkable, with no noted lesions or swelling.
The right tympanic membrane and the left tympanic membrane were intact with cone of light. No
noted discharge.
Nose: The nasal septum was midline with no deviations or septal spurs. No congestion or erythema
was appreciated. On posterior rhinoscopy, there was no noted post-nasal drip, the turbinates and
eustachian tube openings were visualized with no noted obstruction. No noted tenderness of the
maxillary sinuses noted on palpation.
Oral: Oral cavity examination revealed tongue and uvula in midline. No noted masses, tonsillar
enlargement or ulcerations in the oral cavity. Noted no carious teeth.
Indirect Laryngoscopy and Neck Exam: There was left vocal cord paralysis but no laryngeal
mass. There was a 8 cm x 6 cm x1.5 cm soft doughy non-tender mass noted on the anterior neck
which moves with deglutition. Trachea palpated to be slightly deviated to the right. No noted
cervical lymphadenopathy.
TASK 1: Translate the above findings into the ENT Physical Examination drawings then
take a picture or scan. (10%)
TASK 2: Based on the history and PE give at least 3 differential diagnoses and briefly
explain. (10%)
DIAGNOSTICS:
The following are the diagnostic findings for our patient
Thyroid Function Tests FT3 2.13 UIU/mL (normal)
FT4 11.80 UIU/mL (normal)
TSH 0.898 PMOL/L (normal)
Fine Needle Aspiration Bethesda Category II: Benign
Biopsy
Neck Ultrasound Right lobe measures 3.7 x 1.6 x 2.0 cm
Left lobe measures 8.1 x 5.2 x 3.8 cm
There are two hyperechoic nodules seen at the R thyroid. There
are two cystic masses seen at the left thyroid. The largest cystic
lesion measures 4.4 x 3.4 cm. No noted microcalcifications.
Isthmus is unremarkable.
No enlarged lymph nodes, no mass seen in both neck spaces.
Great vessels are intact.
Impression:
1. Nodular right thyroid
2. Complex cysts, L thyroid
3.. No enlarged lymph nodes
A> TASK 3: Based on the history, PE and diagnostics give your complete assessment or
diagnosis. (5%)
P> TASK 4: What are the plans for the patient? (15%)
A. Pharmacologic if any
B. Diet if any
C. Maneuvers if any
D. Lifestyle modification if any
E. Other diagnostics
F. Surgical option/s
G. Follow-up or admission
SURGICAL PLAN:
Assuming the patient underwent or was diagnosed with multi-nodular non-toxic goiter rule out
cancer, with left vocal cord paralysis. She was advised admission to undergo total
thyroidectomy.
WARD 10 ADMISSION:
The patient was admitted at Ward 10. She underwent total thyroidectomy as an Elective
OR. The following were the OR findings: Right lobe measuring 4 x 3 x 3 cm, left lobe 7.0 x 4.5
x 3.2 cm, with noted heterogenous nodules and cysts on both lobes.
Day 1 post-op the patient complained of numbness of the extremities and lips. On PE
noted twitching of facial muscles on tapping on the area anterior to the external auditory canal
(positive Chvostek sign).
TASK 5: What are the possible complications of doing a total thyroidectomy? Explain the
signs and symptoms of the complications (things to watch out for). (15%)
TASK 6: What is most likely complication that the patient experienced? What is the
treatment or management? (10%)
The patient was managed, given Calcium gluconate drip, calcium with vitamin D tablets.
Hypocalcemic symptoms resolved. She eventually got well.
TASK 7: What is the discharge diagnosis of the patient? (5%)
Pending histopathology, choose between:
Multinodular non-toxic goiter, Left vocal cord paralysis or Thyroid Cancer with left vocal cord
paralysis.
TASK 8: Write the prescription for the patient. Scan or take a picture and attach. (15%)
The post-op medications given to the patient were the following:
Celecoxib 200mg/cap 1 cap 2x a day for 7 days or as needed for pain
Calcium carbonate 600 mg + Vitamin D 400 unit / tablet, 2 tabs at lunch, 2 tabs at dinner
Mupirocin ointment, apply once a day on post-operative site
(Oral antibiotics are not routine)
(optional to start Levothyroxine 100ug/tab, 1 tab once a day on empty stomach)
The patient was advised to have the post-op labs done: serum Calcium, albumin
Follow-up one to two weeks for suture removal, final histopathology results, hormone
replacement, and additional treatment planning.
TASK 9: In your own words, preferably in Filipino, write your script on how you would
explain the discharge diagnosis, prescription, other plans and follow-up to the patient.
(15%)
