Clinical case discussion - Goitre

I'm Dr. Amit Keshore and I welcome you to our segment of case discussion and today we will focus on the thyroid gland. As you all know, thyroid gland is dealt with in detail in medicine as well as surgery because the thyroid disease is primarily a medical problem but has a lot of surgical intervention required in many of its pathologies. So today's case discussion is going to focus on the thyroid gland. So what is your name, doctor? I'm Ranadeep. And what are you doing right now? I'm doing my final MBBS instrument, I'm at your call.

Okay, so would you like to start with today's case? Yes. Kamala, a 20-year-old female Hindu patient who is a resident of Varangal district came with the presenting complaints of swelling in the middle of the neck since one year. So why is address important in this patient? Because it's a neck swelling, it could be a thyroid and thyroid can arise in endemic areas of iodine deficiencies. So to rule out that I inquired about her address. So that is correct. So thyroid disease could be endemic in nature. Certain areas are more predisposed to having thyroid problems.

Can you name some areas that you know? Mountaineers areas like Himalayas. So in India, the Himalayan sub-Himalayan plains and the Himalayan areas have a predisposition. Yes. Can you name some globally? Alps. Yes, the alps. Andes. Yes, the andes. Yes. So since the world is becoming a global village and since you're going to be traveling abroad in a few years to gain further knowledge, I'm sure that you should have a little bit of a global perspective. The mountainous regions are predisposed to iodine deficiency and therefore you could get

a goiter. Why did you ask for age in this particular patient? Different conditions of thyroid present and different age groups, like just like simple goiter present during the physiological stresses like pregnancy, pubertal age, but that's correct. So this patient is 20 years old and has gone past her puberty and how long has the swelling been there? Since when is it? So she's 20 years old and is she pregnant? No. So she is not pregnant. This could go a little against the diagnosis but it is more likely that a physiological

swelling of the thyroid gland occurs at times of physiological and metabolic needs as during a growth spurt, as during puberty and as during pregnancy. So as you mentioned, age is very important. Go ahead. She came with the presenting complaints of swelling in the front of the neck since one year. So you have to use simple language when you talk about the presenting complaint and the history of the patient so that it's in the language of the patient or the translation into English, but it has to be the simple language.

Yes. So you have to deal with the swelling in the front of the neck. Don't say that she had a thyroid swelling in the anterior aspect of the neck which would be a wrong way of presenting. Go ahead. Her history of present illness began one year back when she noticed the swelling in the middle of the front of the neck. It is insidious in onset and it progressed to the present size. So the swelling was slow growing. Insidious would be a medical terminology. So therefore it would be slow growing.

And then why did you ask for this, whether it was slow or rapid growing? Malignant tumors are usually grow fast. So malignancies tend to grow faster than benign conditions. Even infectious conditions. Okay, no, but is there any particular condition that you know where there's a rapid increase in size of the thyroid gland? No. So in case there's a hemorrhage into a cyst, there could be a sudden onset of pain or there could be a slight increase in the size of the gland. Go ahead. It's not associated with any pain or fever, sir.

So as I mentioned, pain would be present in which conditions? Infections, hemorrhage into cysts. So in case there is an infection or it is a case of thyroiditis. I mean, latest stages of malignancy. Latest stages of malignancy where nerves are involved. Yes, there could be pain. And what was the other symptom you asked for? Fever. Fever. So where would you get fever? Infectious conditions. So not all thyroiditis is due to infections. Only some thyroid pathologies are due to infections. Thyroiditis in general could also be autoimmune. So you have to use the term thyroiditis as opposed to an infectious.

Go ahead. There is no history of any other swellings in the neck. Why did you ask for a history of other swellings in the neck? One is to rule out secondaries in the lymph nodes if it's malignant, you know, sir. And even tuberculosis lymph nodes can be multiple involving on both sides. So let us limit to this particular case you were looking for secondary lymph nodes.