PBL Thyroid

swellings
Dr.Sundar Prakash

CASE 1

History

A 45-year-old woman is referred to the general surgical outpatients after

her GP noticed a swelling in the neck. On questioning, the patient reports
losing about a stone in weight over the preceding 3 months, despite having
an increased appetite. She also complains that she always feels hot and has
to sleep on top of the bed covers at night. Her bowel motions have been
loose.
Examination

The patient is thin, irritable and has a noticeable fine resting tremor. Her
peripheries feel warm and she has a resting heart rate of 110/min, with a
blood pressure of 150/90 mmHg. On examination of the neck, there is a
smooth moderate enlargement of the thyroid gland, which moves on
swallowing. ere is protrusion of the eyes with lid retraction. Her visual
acuity and eye movements are normal. There is no associated
lymphadenopathy.
Questions

Case 2
A 35 years old female complained of weight gain for the
past 3 years. She has a swelling in front of her neck for
the past 3 years. She also complained of lethargy and
menstrual disturbances. She has constipation. She
sought medical treatment and after 6 months she lost
weight. Discuss.

CASE 3
History
A 40-year old female patient presents with a swelling in the lower part of
right side of the neck. There are no symptoms of toxicity or
hypothyroidism. On examination, the patient has a pulse rate of
70/minute. There is no tremor.
On examination
The swelling is seen on the right side of the neck and moves with
deglutition but without any movement with protrusion of the tongue. The
swelling is of about 4 3 cm size, firm in consistency. The surface of the
swelling is smooth. There is no fixity of the swelling. The lower limit of
the swelling is visible and palpable. The trachea is shifted to the left side.
The left lobe of the thyroid is not palpable. The carotids are normally felt.
There are no regional nodes. There is no clinical evidence of toxicity.
Examination of the oral cavity is normal. Examination of the skull is
normal.
Questions
1. What is your diagnosis?
2. What is your plan?

CASE 4
History
A 65-year-old female patient presents with a swelling on the left side of the
front of the neck of 5 years duration. For the last 1 year there is rapid increase
in size. There is no history of radiation to the neck or exposure to radiation in
childhood. There is no family history of goiter or breast carcinoma. The patient
is coming from an endemic area. There is no history of hypertension, or
diarrhea. Patient complains of hoarseness of voice for the last 6 months.
On examination
There is a hard irregular swelling of about 8 5 cm size with distinct edges. It
moves with deglutition, but not with protrusion of the tongue. There is
restriction of the lateral mobility of the swelling. The carotid arteries are
displaced backwards on the left side of the neck. There are multiple lymph
nodes on the left side of the neck in the posterior triangle (Level 5). The lymph
nodes move more easily in the transverse than vertical plane and do not move
with swallowing.
Questions
1. What is your diagnosis?
2. What is your management?

CASE 5
History
A 30-year-old female patient comes from an endemic area for goiter and presents
with painless swelling in front of the neck of 5-year duration. She complains of
nocturnal dyspnea and discomfort. In the recumbent position the patient gets
dyspnea when she is lying on the left side. There are no symptoms of toxicity.
On examination
Her pulse rate is 72/min. There is no tremor of the outstretched hands. The jugular
veins are distended. A few dilated veins are seen over the swelling and upper chest.
On Pembertons test there is congestion of the face and distress. There is
asymmetrical nodular swelling in the lower half of the neck with up and down
movements on swallowing. The swelling has irregular shape. The lower border of
the swelling is not visible and palpable. The nodules in the thyroid are having
varying consistency, some are firm, some feel hard and some are soft in
consistency. The nodules in the central part (isthmus) are more prominent. There is
no fluctuation or transillumination. The trachea is deviated to the right. There is no
bruit over the upper pole on auscultation. The cervical lymph nodes are not
enlarged.
Questions
1. How will you manage this patient?

CASE 6
A 48 years old female has a swelling in front of the neck
for the past 1 year. There was a sudden increase in size
of the swelling for the past 2 months. Patient developed
another swelling in front of the scalp which was pulsatile
in nature. How will you proceed?