26yr with Papillary Carcinoma Thyroid

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"

Date of Admission- 19/02/2022

A 26 year old female presented to OPD with chief complaints of Swelling in the neck      since 1 year 5 months.

HISTORY OF PRESENT ILLNESS

Patient was asymptomatic since 1 year 5 months and then she noticed swelling in front of neck on the left side. The swelling was insidious onset and gradually increased in size, for which she underwent Left Thyroidectomy on 24/11/2021. The Biopsy showed variant Papillary Carcinoma Thyroid, for which she is admitted at present. 

HISTORY OF PAST ILLNESS:

Completion Thyroidectomy

No h/o similar complaints at present.

No h/o other swelling in neck.

No h/o pain / fever.

No h/o difficulty in swallowing or symptoms of hypo/hyperthyroidism.

Patient was on tab. THYROXINE 150mcg for 4months and 100mcg since 1week.

PERSONAL HISTORY

 Normal appetite 

Bowel movement is Normal.  

Menstrual history:

Age of Menarche:13

LMP: 20/01/22.

No addictions.

Sleep cycle: Adequate

FAMILY HISTORY:

No history of Thyroid.

GENRAL EXAMINATION 

Patient is conscious, coherent, co-operative.

There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy

VITALS

Temperature- Afebrile.

Pulse rate- 79  bpm

Respiratory rate - 17/ min

BP- 110/70

SYSTEMIC EXAMINATION:

Cardiovascular System

Thrills-  No

Cardiac sounds- S1, S2 heard.

Cardiac Murmurs: No.

RESPIRATORY SYSTEM

Dyspnoea: No.

Wheezes: No.

Position of trachea- central

Breath sounds- vesicular

Adventitious sounds- No

 

ABDOMEN

Shape of abdomen- scaphoid

NO tenderness

Palpable mass- No.

Hernias orifices- Normal.

Free fluid- No.

Bruits-  No.

Liver- Not palpable

Spleen- Not palpable

Bowel sound- Yes

CENTRAL NERVOUS SYSTEM 

Patient is conscious 

Speech- normal

No sign of meningitis 

Motor and sensory system- Normal

Cranial nerves- intact

Investigation 

RFT

LFT

ECG Report:

Color Doppler Report:

Biopsy Report:

Thyroid Hormone levels:

 

On 8/02/2022

On 19/02/2022

Ultrasound Scan Report:

Plan of Treatment:

Total Thyroidectomy.

Surgery was done under strict aseptic conditions.