A WOMAN 62 YEARS OLD WITH BILATERAL THYROID TUMOR

T4aN1M0 WITH LYMPHANEDOPATHY REGIO COLLI DEKSTRA

By:
Yuanita Citra Syafitri
G99162066

Supervisor:
Dr. dr. Kristanto Yuli Yarsa, Sp. B (K) Onk.

DEPARTMENT OF SURGERY
FACULTY OF MEDICINE UNS/ RSUD DR. MOEWARDI
SURAKARTA
2017
 Medical Record

A. Anamnesis
1. Patient Identity
Name : Mrs. S
Age : 62 years old
Sex : Woman
Address : Sukoharjo
Job : Housewife
Medical Record Number : 0138xxxx

2. Chief Complain
Bilateral lump in regio colli

3. Present Illness
Patient came to Moewardi Hospital with chief complain bilateral
lump in regio colli since 7 years ago. The lump size is as big as a marble
and getting bigger since 4 months ago and now the size of the lump is
as big as chickens egg. Single bilateral lump, one on the right side and
one on the left side. The patient feels there is a wedge in the neck,
especially when swallowing. Beside that, chief complain about the lump
in right neck (under her ear) since 5 month ago. The lump size is as big
as a marble and the lump has the same size from the first time she felt.
She didnt feel pain in the lump. Then, chief also complain she had
cough and after the sputum came out she felt relieved and sometimes
she felt dyspneu. Before this, she was never checked the lump to the
hospital. She also never took any medicine yet.
She said, she felt uncomfortable with it. There is no fever,
difficulty in swallowing, vocal change, palpitation, cold sweat weight or
appetite loss. No complain in defecation and mikturition.
 4. Past Illness History
History of same illness : (-)
History of allergic : (-)
History of hypertension : (-)
History of diabetes mellitus : (-)
History of heart disease : (-)
History of operation procedure : (-)
History of tumor : (-)

5. Familys Illness History

History of same illness : (-)
History of allergic : (-)
History of hypertension : (-)
History of diabetes mellitus : (-)
History of heart disease : (-)
History of tumor : (-)

6. Economic and Social History

She is a housewife. Now, she lives together with her husband and 2
children. Patient is treating in Moewardi Hospital by using BPJS.

B. Physical Examination
1. Consciousness : compos mentis
General condition : good
Performance status based on Karnofsky score : 90%
2. Vital sign
Blood pressure : 120/70 mmHg
Heart rate : 82 x/ minute
Respiratory rate : 20 x/ minute
Temperature : 36,30C per axilla
3. Nutritional status
 Weight : 55 kg
Height : 162 cm
BMI : 20,95 (normoweight)

4. General Survey
Head : mesocephal
Eyes : anemic conjunctiva (-/-), icteric sclera (-/-)
Ears : normotia, inflammation (-/-), secret (-/-)
Nose : symmetric, inflammation (-/-), secret (-/-)
Mouth : sianotic (-)
Neck : localized status
Thorax : normochest, symmetric
Pulmo
Inspection: movement of hemithorax left = right, retraction (-/-)
Palpation: fremitus tactile right = left
Percussion: sonor/ sonor
Auscultation: vesicular base sound (+/+), additional sound (-/-)
Heart
Inspection: ictus cordis not visible
Palpation: ictus cordis is palpable, thrill (-)
Percussion: heart border normal
Auscultation: heart sound I-II regular, additional sound (-)
Abdomen :
Inspection: scar (-), inflammation (-), distended (-)
Auscultation: bowel sound (+) normal, 11 x/ minute
Percussion: tympanic
Palpation: pain (-), liver and spleen not palpable
C. Localized Status
R. Colli Anterior
Inspection : lump bilateral, ulceration (-), eritem (-)
Palpation : nodul bilateral was palpated, its size: right side 7x5x2 cm,
left side 6x4x3 cm, immobile, smooth surface with hard
consistensy, pain (-), join the swallowing movement, have
the same temperature as the body temperature

Regio Colli Dextra :

Inspection : lump under the ear, ulceration (-), eritem (-)

Palpation : nodul was palpated, its size: 3x2x2 cm, mobile, smooth
surface with firm rubbery consistensy, pain (-), have the
same temperature as the body temperature
D. Assesment I
Thyroid tumor suspect malignancy with lymphadenopathy regio colli
dekstra dd hiperthyroid dd stroma thyroid
E. Plan I
1. Check blood routine
2. Check TSH, FT3, FT4
3. Chest X-ray
4. USG thyroid
5. FNAB procedure
6. Consult oncology surgery