A 65 year old female from sundergarh presented with swelling in front of neck gradually increasing size over 3 years without airway compromise,complications,any other comorbid conditions , diagnosed as hypothyroidism 2 yrs back & is on treatment with levothyroxine with FNAC diagnosis diffuse colliod goiter pattern & ECG showing RBBB pattern.

1. A 65 YEAR OLD FEMALE
DIAGNOSED WITH COLLOID
GOITRE POSTED FOR
HEMITHYRIODECTOMY UNDER
ANAESTHESIA
By
Dr sapan kumar jena
MD Anaesthesiology

2. PATIENT DETAILS
 Name : Tilotama seth
 w/o : Late Gourisanker seth
 Age /sex : 65 yr female
 Address: sankara , sundergarh
 Weight: 58 kg
 Height : 150cm
 Date of admission: 11 july 2018
 Regd no: 2729

3.  Chief complints:
 Swelling in front of neck – 3 years
 History of present illness:
 Patient was apparently alright 3 years back ,to start
with she noticed a swelling in front of neck which is
gradually increasing size . It was not associated
with pain , difficulty in breathing ,difficulty in
swallowing or any voice change. There was no
history of tremor ,palpitation, diarrhoea ,
constipation.
 Bowel & bladder habits normal.

4.  History of past illness:
 She is a known case of hypothyriodism ,taking
Levothyroxine 100 mg once daily since 1 year
 No h/o TB,DM,Hypertension,asthma ,seizure
disorder,sickle cell disease
 No past surgical history
 Family history : nothing suggestive
 Treatment history:
 Taking levothyroxine 100 mg once daily since 1 yr
 Personal history :
 Belongs to low socioeconomic status
 Married & blessed with two children
 Menstual history:
 Menopause 15 yr back

5. GENERAL EXAMINATION
 Patient conscious ,oriented , afebrile
 Height : 150 cm
 Weight : 58 kg
 Pallor ++,
 No icterus, cyanosis,clubbing, lymphadenopathy,edema
 No proptosis or lid lag
 PR =65/min regular ,good volume and character, all
peripheral pulses well felt with no radioradial or
radiofemoral delay.
 BP: 110/70 mm Hg rt arm supine position
 RR: 14/min regular abdomino thoracic
 Temp : 98.2 ºF

6. AIRWAY EXAMINATION
 Mallampatti grade : II
 Mouth opening : allowing 3 fingers
 Thyromental distance = 6.8 cm
 Sternomental distance = 13cm
 Dentition : normal ,no loose tooth,bucked tooth or
artificial dentures
 Cervical spine : no resticted mobility

7. LOCAL EXAMINATION
 Inspection:
 Size : 4cm x 3 cm
 Shape: globular
 Location : at middile of neck
 Palpation :
 Diffuse ,smooth surface, regular margin , firm,
nontender,mobile ,no local rise of temprature, no
pulsation
 Moves with deglution, not with protrusion of tongue
 Getting below the swelling is possible
 No cervical lymphadenopathy
 Auscultaion : no bruit is heard

8. SYSTEMIC EXAMINATION
 Respiratory system:
 chest B/L symmetrical,trachea central
 B/L vesicuar breath sounds , no added sound
 CVS : S1 S2 heard, no murmer
 Per abdomen : soft nontender , no hepatomegaly ,
spleen is not palpable
 CNS: cranial nernes intact , higher motor functions
normal . Deep tendon reflexes normal

9. PROVISIONAL DIAGNOSIS
 Diffuse colloid goiter

10. INVETIGATIONS
 Hematology:
 Hb: 10.4 gm/dl
 DC = N 78 L 20 E2
 TLC= 7800/cumm
 Biochemical profile
 Serum Na+ = 140 mmol/L
 S. K+ = 3.6 mmol/L
 S. urea= 26 mg/dl
 S. creatinine= 1.1mg/dl
 RBS= 128
 Coagulation profile
 BT= 2 min 60 sec
 CT= 4 min 15 sec

11.  Serology : HIV,HBV,HCV are nonreactive
 Thyriod profile:
 Total T3= 0.94 ng/ml
 Total T4= 10.09 µg/dl
 TSH = 1.22 µIU/ml
 ECG: RBBB

13.  FNAC : colliod goiter with cyctic degeneration

14. FINAL DIAGNOSIS
 Diffuse colliod goiter

15. SUMMERY
 A 65 year old female from sundergarh presented
with swelling in front of neck gradually increasing
size over 3 years without airway
compromise,complications,any other comorbid
conditions , diagnosed as hypothyroidism 2 yrs
back & is on treatment with levothyroxine with
FNAC diagnosis diffuse colliod goiter pattern &
ECG showing RBBB pattern.
 She was posted for hemithyriodectomy under
anaesthesia

16. PLAN OF SURGERY
 Hemithyriodectomy

17. PLAN OF ANAESTHESIA
 General anaesthesia with endotracheal intubation
and positive pressure ventilation

18. PREANAETHETIC CHECK UP
 Nil per oral 8 hours before surgery
 Adequate blood for intraoperative requirement
 Tab ranitidine 150 mg night before surgery
 Tab alprax 0.25 mg night before surgery
 Levothyroxine to be continued on morning of
surgery
 ENT consultation for indirect laryngoscopy
 Lateral view X ray of neck

19. MONITERING
 Pulse oxymetry
 NIBP
 ECG
 EtCO2
 Temperature monitioring

20. ANAESTHETIC MANAGEMENT
 Premedication:
 Inj glycopyrrolate 0.2mg iv
 Inj midazolam 1.5mg iv
 Inj nalbuphine 10 mg iv
 Inj ranitidine 50 mg iv
 Inj ondansetron 4mg iv
 Induction :
 Inj Propofol 100 mg iv
 Inj succinyl choline 100 mg iv
 Intubation :
 Under direct laryngoscopy ,intubation performed with
6.5 mm ID cuffed flexomettalic tube fixed at right angle
of mouth

21. ANAESTHETIC MANAGEMENT
 Maintainance :
 Inj vecuronium 5mg iv loading dose
 N2O :O2 =2:1
 Sevoflurane inhation
 Intraoperative period:
 IV fluid: ringer lactate 1000 ml in first hour, 750 ml each
in 2nd & 3rd hour
 One unit of blood was infused
 Inj diclofenac 75 mg iv infusion
 Inj hydrocortisone 200 mg iv
 inj vecuronium 1mg at 30 min interval

22. ANAESTHETIC MANAGEMENT
 Reversal :
 Inj neostigmine 2.5 mg iv
 Inj glycopyrrolate 0.5 mg iv
 Extubation : done after thorough suctioning &
regular breathing pattern
 Post operative
 Nil per oral for 6 hours
 Vitals monitoring
 O2 inhalation
 IVF ringer lactate 500ml over 6 hours
 Inj diclofenac im 8hourly
 Inj ranitidine 50 mg iv 8hourly
 Antibiotic prophylaxis