A MAN 40 YEARS OLD WITH THYROID TUMOR

By:
Zahra Afifah Hanum
G99172162

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

DEPARTMENT OF SURGERY
FACULTY OF MEDICINE UNS/ RSUD DR. MOEWARDI
SURAKARTA
2018
 Medical Record

III. Anamnesis
1. Patient Identity
Name : Mr. A
Age : 40 years old
Sex : Male
Religion : Islam
Address : Laban Wetan, Sukoharjo
Date of hospitalized : 4 July 2018
Date of examination : 5 July 2018
Medical Record Number : 0130xxxx

2. Chief Complain
Lump in neck region.

3. Present Illness
Patient came to Moewardi Hospital with chief complain there’s
lump in neck region since three and half years ago. At first, the patient
didn’t realize about the lump until he found out about the lump when he
was hospitalized in Moewardi at 2015. As the time goes by, the size of
the lump has become bigger and now the size of lump is as big as tennis
ball in both of his neck. The patient also stated that the lump has been
painless until present time even when the lump is touched.
The patient has no other complain. He has no problem of
swallowing food, breathing, talking, and doing his daily activities. But
he feel worried about his lump. There is no loss of appetite and weight
loss. The patient didn’t complain about sweating and trembling on a
hand since the first time the lump appeared. There’s no problem with
defecation and urination. There’s no fever, nausea, vomit, and headache.
 The patient is from Sukoharjo, he currently doesn’t live near the
beach nor mountain. He stated he has no history of radiation. He was
first treated in Puskesmas Sukoharjo, then being sent to PKU
Muhammadyah Hospital, and finally is being referred to Moewardi
Hospital for advance treatment.
Actually he already came and hospitalized in Moewardi Hospital
about three months ago. He was sent home and asked to wait for the
surgery and control to oncology surgery clinic because he needs to fix
his lab examination before the procedural.

4. Past Illness History

History of same illness : (-)
History of allergic : (-)
History of hypertension : (-)
History of diabetes mellitus : (-)
History of heart disease : (+)
Chronic Heart Failure (hospitalized in Moewardi – 2015)
History of operation procedure : (-)
History of tumor : (-)

5. Family’s 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

 The patient already married and live in his own house. The patient is
currently treated in Moewardi Hospital with National Health Insurance.

7. History of Nutrition and Habitual

Meal : 3 times a day with rice and side dishes. The
patient prefer salty food.
Smoking : (+)
>15 years
Alcohol consumption : denied
Regular exercise : denied

B. PHYSICAL EXAMINATION
I. General Circumstance
1. General circumstance : compos mentis GCS E4V5M6,
performance status based on Karnofsky score 90%.
2. Vital sign :
Blood pressure : 130/80 mmHg
Heart rate : 80x/minute
Respiration rate : 18x/minute
Temperature : 36,50 C

II. General Survey

1. Skin : icterus (-), dry (-)
2. Head : mesocephal, alopecia (-)
3. Eyes : pale conjunctiva (-/-), icterus sclera (-/-)
4. Nose : Symmetric, inflammation (-/-), secretions (-/-)
5. Ears : Normotia, inflammation (-/-), secretions (-/-)
6. Mouth : wet mucosa (+), cyanosis (-), mouth ulcers (-)
7. Neck : Check the localized status
8. Lymph gland
 Submandibular : lump (-/-), pain (-/-)

Sublingual : lump (-/-), pain (-/-)

Supraclavicula : lump (-/-), pain (-/-)

Axilla : lump (-/-), pain (-/-)

9. Cor
I: ictus cordis not visible

P: ictus cordis not strong lift

P: the heart border impression is not widen

A: heart sound I-II normal intensity, regular, noisy (-)

10. Pulmo
I: symmetrical chest development (+), retraction (-)

P: fremitus right = left

P: sonor/sonor

A: vesicular base sound (+/+), additional sound (-/-)

11. Abdomen
I: abdominal wall parallel to the chest wall, distension (-)

A: bowel sound (+) normal

P: tympanic

P: tenderness (+), pain (-), mass (-)

12. Extremity: CRT < 2 seconds

Cold Oedema
- - - -

- - - -

III. Localized Status

R. Colli
a. Inspection: Lump bilateral, skin intact, ulceration (-), erythema (-),
smooth surface (+), skin color change (-)
b. Palpation: mass palpable with the rubbery consistency, the size is
about 10x4x4 cm, smooth surface, mobile, follows the swallowing
movement, clear borders, pain (-), temperature change (-).

IV. Assessment I
Thyroid Tumor T3NxMx suspect Non Toxic Goiter dd toxic goiter dd
malignant

V. Plan I
1. Education
2. Check blood routine
3. Check TSH, FT3, FT4
4. Chest X-ray
5. USG thyroid
6. Biopsy for Pathologic Anatomy Purpose
(FNAB/Incision/Excision)
7. Pro Subtotal Thyroidectomy waiting for procedural
8. Consultation with anesthesiologist and cardiologist for
procedural tolerantion
VI. Attachment

(Right View)

(Front View)

(Left View)