H&P

Chief Complaint: “Lump in neck” x 6 months

History of Present Illness:

31 y/o female patient with PMH of Hashimoto thyroiditis presents to PAT prior to scheduled right thyroidectomy. Patient states that she noticed a lump in her neck 6 months ago but ignored it because it was it small and wasn’t causing any symptoms but now she noticed it has gotten slightly larger and has been causing her to have slight discomfort when she swallows. Patient states that she had an ultrasound done last month which showed multiple thyroid nodules and slightly enlarged right thyroid lobe. She underwent FNA biopsy with her Endocrinologist. Pathology results was positive intermediate high (70%). Patient denies SOB, voice changes, chest pain, palpitations, nausea, vomiting, fatigue, family history of thyroid disease, radiation exposure, and weight gain or loss. 

Past Medical History:

  • Hashimoto thyroiditis

Past Surgical History

  • None

Medications: 

  • Levothyroxine
  • Denies any supplements, herbals, or use of OTC medications

Allergies: 

  • No known allergies to food, contrast, environmental, or medications

Family History

  • Father alive with history of HLD
  • Mother alive with DM

Social History

  • Denies smoking, drinking, and illicit drug use.

Review of Systems

General

Denies fever, chills, fatigue, weight loss/gain, loss of appetite, night sweats, diaphoresis and weakness.

Skin

Denies hair loss, skin discolorations, moles/rashes, pruritus, changes in skin texture, and excessive dryness. 

Head

Denies headache, head trauma, vertigo.

Eyes

Denies visual disturbances, lacrimation, photophobia, and pruritus. 

Ears

Denies pain, discharge, or tinnitus

Neck 

Admits to lump in neck, Denies neck pain, and stiffness/decreased range of motion

Respiratory

Denies SOB, DOE, cough, orthopnea, wheezing, hemoptysis, cyanosis, and PND.

Cardiovascular System

Denies CP, HTN, palpitations, irregular heartbeats, syncope, edema/swelling of ankles/feet, and having any known heart murmur.

Gastrointestinal System

Denies abdominal pain, pyrosis, intolerance to specific foods, decreased appetite, dysphagia, flatulence, jaundice (dark urine and light clay colored stool), changes in bowel habits, constipation, diarrhea, frothy stool, heartburn, hemorrhoids, rectal bleeding, nausea, vomiting, past abdominal surgieries, and melena.

Genitourinary System

Denies urinary urgency, urinary frequency, dysuria, oliguria, flank pain, changes in color of urine, urinary incontinence, nocturia, and polyuria.

Musculoskeletal System

Denies deformity, arthritis, muscle/joint pain, redness and swelling.

Endocrine System

Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, goiter, diaphoresis and hirsutism.

Physical Exam

Vital Signs

BP Right Arm Sitting: 112/70

HR: 68 Regular 

RR: 18 BPM, Unlabored, No Accessory Muscle Use

Temperature: 37 *C

02 Sat: 98% Room Air

General: Pt appears stated age, well groomed, A&Ox3, and in no apparent distress. 

Skin: Warm and moist, good turgor, nonicteric, no cyanosis, and discoloration.

Neck: Right lobe nodule: 1.5 cm x 1 cm, firm, non-tender, mobile with swallowing.

No lymphadenopathy noted. Neck symmetrical, no visible swelling. Trachea midline and normal range of motion.

Chest: Symmetrical, no obvious trauma/deformities. Respirations unlabored, no paradoxic respirations, and no accessory muscle use. Clear to auscultation B/L. 

Heart: Regular rate and rhythm. S1 and S2 are distinct. No murmurs, no friction rubs, no S3, and no S4 sounds appreciated.

Abd:  Abdomen is symmetric, soft, and nondistended with BS present in all 4 quadrants. Non-tender to palpation in all 4 quadrants. No murphy sign appreciated, no psoas sign appreciated, no obturator sign appreciated, and no rovsing’s sign appreciated. No guarding, no rebound tenderness, no CVA tenderness. 

Cranial Nerves Exam: 

CN VII: Facial expressions intact, clearly enunciates words 

CN IX and X: Difficulty swallowing, no hoarseness, uvula midline with elevation of soft palate, gag reflex intact

CN XI: Full ROM at neck with 5/5 strength and strong shoulder shrug 

Labs: 

TSH: 1.25

Calcium: 9.2 mg/dL

Imaging: 

Ultrasound Thyroid: Mildly enlarged right thyroid lobe. Mildly heterogenous thyroid gland with bilateral nodules. Dominant 1.9 cm posterior right midpole solid nodule. 1.3 cm hypoechoic right upper pole solid nodule. 1 cm right medial midpole peripherally calcified nodule. 

Thyroid FNA Biopsy: Right thyroid gland: AUS (Bethesda III), Thyroseq positive – 70% malignancy NRAS mutation

Assessment:

31 y/o female patient with PMH of Hashimoto thyroiditis presents to PAT for scheduled right thyroidectomy. PE is significant for a right lobe nodule 1.5 cm x 1 cm, firm, non-tender, mobile with swallowing. Ultrasound significant for mildly heterogenous thyroid gland with bilateral nodules and biopsy significant for right thyroid gland AUS (Bethesda III), thyroseq positive – 70% malignancy. Patient to have right thyroidectomy due to likelihood of thyroid cancer. 

Plan:

  • Right thyroidectomy 
  • Single 8 mg dose of dexamethasone to prevent PONV
  • Discuss risks of thyroidectomy including hypocalcemia, recurrent laryngeal nerve injury, hoarseness, or vocal cord paralysis. 
  • Begin patient on levothyroxine and calcium after surgery