18 year old female came with swelling in front of the neck
E LOG GENERAL MEDICINE.
Hi, I am G Sai Karthik, 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
- This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
- * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required
Chief complaints :
A 18 year old female , resident of sirikonda , agricultural worker by occupation , came to the OPD with chief complaint of swelling in front of the neck slightly towards right side since 8 years.
History of present illness :
Patient was asymptomatic 8 years back, and then noticed a swelling in front of the neck which was
Incidious in onset , gradually progressed to present size.
Difficulty in speech since 8 years.
History of weight gain since 3 years.
Difficulty in swallowing and pain during swallowing since 2 months.
She also complains of generelised weakness and lethargy.
No aggrevating or releiving factors.
No history of fever.
History of past illness :
She is a known case of hypothyroidism since 8 years and is on regular medication
Thyroxin sodium 100mcg
No diabetes
No hypertension
No TB
No CAD
No epilepsy
No Asthma
History of blood transfusion 3 years ago
History of fracture in the left forearm ( fell during running ) 5 months ago and she under went a surgery
Family history :
No significant family history
Allergies :
No allergies
Drug history :
Thyroxin sodium 100mcg once daily.
Personal history :
Appetite is normal
Mixed diet
Bowel and bladder habits are regular.
Sleep is adequate.
No addictions.
PHYSICAL EXAMINATION :
A. General Examination
Oral consent is taken.
Examined in a well lit room.
Conscious , coherent and cooperative
Moderatly built and nourished
Pallor is present.
Icterus is absent.
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema is absent.
Vitals :
Temperature: afebrile
Pulse: 80 bpm
Respiration: 16/min
Blood pressure: 110/70 mmhg
Spo2: 96%
PHYSICAL EXAMINATION :
A.Cardio vascular system :
Cardiac sounds : S1 and S2
No thrills
No murmurs
B.Respiratory system :
Position of trachea : centre
Breath sounds : vesicular
No added sounds.
C.Abdomen :
Shape of abdomen : normal
No tenderness
No palpable mass
No organomegaly
LOCAL EXAMINATION :
Inspection :
A solitary swelling in front of the neck
of 5 × 6 cm in size
irregular in shape
extending from strenoclidomastoid laterally to the midline of neck , superiorly from thyroid cartilage to 3cm above to suprasternal notch
Skin over the swelling normal
Surrounding skin normal
No other swellings
Pallor
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