18 year old female came with swelling in front of the neck

1 Nov , 2023

E LOG GENERAL MEDICINE 

Hi, I am G. Akshara , 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 aChief complaints and duration.

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