Objectives

General Objectives

The study aims to widen the horizons of our nursing skills and knowledge by
understanding and imparting gathered information through proper execution of nursing
process pertaining to our chosen case Non-Toxic Multi-nodular Goiter. Equipped with
this knowledge and skills, may we able to provide the essential care and services that
will contribute in the improvement of our client’s health status. And also may we apply
the theories we have learned in school that could help in implementing and rendering of
care.

Moreover, may this paper serve as a guide to the succeeding generations of

nursing students who will handle the same case.

Specific Objectives

After the case study and presentation we should be able to:

1. Define what Multinodular Nodular Goiter.

2. To be able to understand and discuss the Anatomy and Physiology of the

underlying diseases of the patient that would later help in the planning and
rendering of care.

3. To understand the process by which Multinodular Nodular Goiter

develops.

4. To determine the various risk factors that contributes to the development

Multinodular Nodular Goiter.

5. To be able to know the pathophysiology or the cause of the disease to

give correct health teaching on how the patient can avoid it.
6. To be able to know the clinical significance of various laboratory and
diagnostic exams.

7. To be able to formulate and implement appropriate nursing care plans.

 8. To be able to determine what drugs are used on treating Multinodular
Nodular Goiter along with its responsibilities.

9. To be able to put into practice and impart essential health teachings for
achievement of patients optimal health.

10. To be able to evaluate if the goals, plan of care and objectives were met.

INTRODUCTION

This case study provides a thorough investigation of a person diagnosed with a certain
disease. This includes the background of the patient, the cause, diagnosis, discussion of
anatomy and physiology with its pathophysiology, laboratory studies, drug study and nursing
interventions. This is an important tool to determine an effective nursing study and nursing care
to patients. This study can serve as a future reference and research.

This is a case of Mrs. D.T., 58 years old, diagnosed with Multinodular Non-toxic Goiter
with a past medical history of hyperthyroidism and undergone of maintenance of PTU for 2
months afterwards thyroid hormones back to normal level. A nontoxic (or sporadic) goiter is a
type of “simple” goiter that may be diffuse (enlarging the whole thyroid gland)
or nodular (enlargement caused by nodules, or lumps, on the thyroid.) The development of
nodules marks a progression of the goiter. The exact causes of nontoxic goiter are not known.
In general, goiters may be caused by underproduction or overproduction of thyroid hormones.
However, a nontoxic goiter is usually characterized by normal thyroid function. Some possible
causes of nontoxic goiter include: heredity (family history of goiters), However, iodine deficiency
is a primary cause of goiter in other parts of the world, particularly in mountainous areas, or
areas that experience heavy rainfall or flooding.

The following factors increase your chance of developing nontoxic goiter: sex: female
(Nontoxic goiter is more common in women than men.), age: over 40 years, family history of
goiter.

Nontoxic goiters usually do not produce noticeable symptoms. However, if you

experience any of the symptoms below, do not assume it is due to nontoxic goiter. These
symptoms may be caused by other, less serious health conditions: swelling on the neck,
breathing difficulties, coughing, or wheezing with large goiter, difficulty swallowing with large
goiter, feeling of pressure on the neck and sometimes hoarseness. On the case of our client
palpable mass and difficulty of swallowing are positive signs.
 Diagnostic examinations includes physical examination of the neck—to assess any
thyroid enlargement, ultrasound —a test that uses sound waves to identify nodules of the neck
and thyroid, blood tests—to assess levels of thyroid hormones (eg, thyroid stimulating
hormone). Thyroid auto antibodies tests may also be done. X-ray of neck and chest for large
goiters—to see if the trachea is compressed.

Thyroidectomy is a surgical procedure to remove a portion or all of the thyroid gland. It is

the treatment of choice in someone whose nontoxic goiter is so large to cause difficulty in
breathing or swallowing. This type of surgery should be performed by a thyroid surgeon.

With a short background of the focus disease in this case study, readers will able
to learn various nursing managements that will enhance their abilities and specially the
student-nurses to perform nursing processes in a situation where immediate
interventions are needed.

Demographic Data

Name: “Mrs. D.T”

Address: 1283 Dama de Noche Moriones Tondo Manila

Birth Place: Manila

Age: 58 years old

Sex: Female

Status: Married

Citizenship: Filipino

Religion: Roman Catholic

Admission Date: August 16, 2010

Admission Time: 10am

Admission Doctor: Dr. X

Chief Complaint: difficulty of swallowing and hoarseness

Admission Diagnosis: Non-toxic Multinodular Goiter

Final Diagnosis: Multinodular Non-toxic Goiter

Operation: Total Thyroidectomy

HEALTH HISTORY

A. FAMILY HISTORY

• Maternal Health History

Her mother has the risk of developing asthma due to genetic make-up
because her grandmother had asthma. Also, her cousin was operated of total
thyroidectomy because of having nodular goiter.

• Fraternal Health History

Her father had no known history of disease.

B. HISTORY OF PRESENT ILLNESS

2 months PTA - the client had past medical history of hyperthyroidism. The
doctor conducted physical examination and found palpable nodules on the right side of
the neck. She was advised to undergo sensitive TSH test and result shows that her
TSH is low and T3 and T4 was elevated. It is found out that she usually eats low iodine
foods such as noodles, can goods and meat products. She was diagnosed with
hyperthyroidism and prescribed PTU 50 mg TID as maintenance to normalize thyroid
hormones. She was instructed to return to OPD after 2 months.

7 days PTA – the client still experiencing difficulty of swallowing and hoarseness
of voice. She tried OTC Drugs such as mefenamic acid hoping to relieve it but then after
several hours she experiences it again. She also tried sleeping but then but then it just
re-occurs. For 7 days she just ate small quantity and soft foods.

3 days PTA – she was alarmed and conscious on her conditions. Still with voice
becoming hoarse, accompanied by difficulty of swallowing.
 On the day of admission - she decided to go to return at Gat Andres Memorial
Medical Center with the chief complaints of difficulty of swallowing and hoarseness of
voice. She has undergone TSH Test and the result for TSH, T3 and T4 were all normal.
She was admitted and as scheduled for total thyroidectomy.

C. Risk Factors associated with the disease

• Non – modifiable Risk Factors

• Age - people older than 40.

• Female – a hormone produced during pregnancy, Human Chorionic

Gonadotropin (hCG), may cause slight uniform enlargement of the thyroid
gland.

• Heredity – genetic make-up of cells making the thyroid gland to

underwent hyperplasia.

• Modifiable Risk Factors

• Poor socioeconomic status – people living in urban area that usually eat
foods having low iodine content and poor nutritional status.

• Iodine Deficiency - low iodine content such as noodles, can goods and
meat products. Thyroid can’t make and release enough T3 and T4 – both
of which contain iodine – and it enlarges in response to excess stimulation
from the pituitary gland.
 REVIEW OF SYSTEM

Examination Thyroid (c/o UTZ result)

Right Lobe 4.5x1.1 x1.9 cm
Isthmus 0.1 cm
Left Lobe 4x1.0x1.8 cm

Both lobes and isthmus are normal in size with smooth contour and homogenous
parenchyma.

Three lesions are noted in the right lobe:

a) Two small thin walled cystic, anechoic lesion are noted in the mid aspect of
the right lobe with transverse diameter of 0.4 cm
b) Complex mass in the right inferior pole, predominantly cystic with a 0.60 cm-
echogenic focus in its superior aspect. The lesion measure
0.67x0.74x0.61cm.
No focal/diffuse solid or cystic lesions in the left lobe and isthmus.

Impression:
- Normal sized Thyroid Gland
- Cystic and complex nodules, RIGHT (palpable nodule)
 NORMAL ANATOMY AND PHYSIOLOGY OF THE THYROID GLAND

INTRODUCTION

Thyroid gland

• the largest gland in a normal adult.

• the gland weighs 15- 25g.

 • It is a highly vascular organ.

• The gland is bilobed and connected by a bridge of

tissue called isthmus.

Function:

• controlled by thyroid stimulating hormone, TSH

from anterior pituitary which is regulated by thyrotropin releasing hormone,
TRH from hypothalamus .

• Thyroid hormones, T3 and T4 in circulation, provide negative feedback on

secretion of TSH and TRH on anterior pituitary and hypothalamus respectively.

REGULATION OF TSH SECRETION:

Hypothalamus TRH Anterior Pituitary TSH Thyroid Gland. T3, T4.

Factors increasing TSH secretion:
1. Anxiety
2. Excitement
3. Fall in free T3 ,T4

There exists inverse relationship between T3 T4 and TSH.

• Thyroid hormones regulate lipid and carbohydrate metabolism.

• They are important for normal body growth.
• Thyroid gland produces two main hormones -T3 and T4.

FORMATION OF THYROID HORMONE

1. Iodine from diet is converted to Iodide which is reabsorbed into thyroid cells
by Iodide pump.
2. Iodide pump is mediated by Na+- K+ dependent ATPase system.
3. Iodide is transported into colloid and gets oxidized by thyroid peroxidase into
iodine, I2.
4. I2 then gets bound to 3 position of tyrosine forming mono- iodo- tyrosine,
MIT and di-iodo-tyrosine, DIT.
5. Thyroid peroxidase and coupling enzymes form T3 and T4.
6. Iodinated T3 and T4 are deiodinated by Iodotyrosine dehalogenase and
secreted into circulation.

TRANSPORT OF THYROID HORMONES:

 Thyroid hormones are transported in blood by:
1. Albumin: Highest capacity to bind thyroid hormones.
2. Thyroid binding globulin (TBG): Least capacity to bind thyroid hormones

3. Transthyretin.

Free thyroid hormones are in equilibrium with protein bound thyroid hormones
in plasma. Free T4 and T3 are physiologically active form. When concentration
of free thyroid hormones is increased in plasma, the rate of entry of thyroid
hormones in tissues is increased thereby maintaining the euthyroid state.

THYROXINE(T4)

1. Normal plasma levels: 3-8 microgms%

2. 99.9% bound to TBG.
3. Longer duration of action, but onset of action is slow
4. Free plasma levels of T4 are less than T3.

TRI IODO THYRONINE( T3).

1. Normal plasma levels: 0.15 microgm%

2. 99.8% bound to TBG and albumin.
3. Duration of action is short but onset of action is rapid.
4. Free plasma levels are higher than T4.

ACTIONS OF THYROID HORMONES:

1. Energy Metabolism: Thyroid hormones stimulate heat production in the body, due to
stimulation of O2 consumption that increases the BMR. T3 and T4 increase the O2
consumption of all tissues except brain, testes, spleen, lymph node, ovary, uterus and
anterior pituitary.

2. Protein Metabolism:
In physiological dose: T4 is anabolic and increases protein synthesis.
IN PHARMACOLOGICAL DOSES, T4 has catabolic effect on body

3. Carbohydrate metabolism:
Thyroid hormone in physiologic dose,
Increase peripheral utilization of glucose, can cause
hypoglycemia.
Increase glucose absorption from intestine
Increase glycogenesis
Increase gluconeogenesis
Decrease breakdown of insulin.

Thyroid hormones precipitate Diabetes Mellitus in hyperthyroid

patients.

4. Lipid metabolism
Increase breakdown of cholesterol in the liver
Stimulate degradation of lipids.

5. Cardiovascular system:
Increase in heart rate.
Increase in force of myocardial contraction.
Increase in systolic BP.
Fall in diastolic BP.
Increase in O2 consumption, leading to cardiac arrhythmias.

6. Growth and development

Thyroid hormone is essential for normal body growth
7. Nervous system
Thyroid hormone is necessary for normal development of nervous
system.

After birth, it is necessary for myelination in axons. If thyroid hormone deficiency

develops before one year, it should be replaced immediately otherwise irreversible
mental retardation may develop. After 2 years, if deficiency develops it can be reversed
by adequate doses of T4.

IN ADULTS, Deficiency causes

Loss of memory, depression
Slow speech
Mentally lethargic

8. GIT:
Essential for intestinal motility. T4 deficiency causes constipation.

HYPOTHYROIDISM HYPERTHYROIDISM
CAUSES :
1. Iodine deficiency in diet 1.Graves disesease
2. Hashimotos thyroiditis 2.Toxic multinodular goiter
3. Pituitary hypothyroidism 3. TSH secreting tumor
4. Hypothalamic hypothyroidism 4. Excess intake of T3, T4.

CLINICAL FEATURES:

1. CALORIGENIC ACTION:
BMR Decreases
Increases.
Goitre
Exophthalmos
Puffiness of face
Cold intolerance
Heat intolerance
Weight gain
Weight loss
Dry, thickened, rough skin.
Skin: warm, moist, soft

2. CNS:
Memory loss, depression.
Anxiety, tremors,
Hoarseness of voice
Nervousness
Decreased tendon reflexes knee jerk.

3. GIT :
Constipation, Anorexia, Diarrhea

4. CVS
Decreased cardiac output
Tachycardia, High output
bradycardia, pericardial effusion.
cardiac failure, dyspnea.

5. Menorrhagia
- scanty periods

6. Hypoglycemia
Hyperglycemia

ANTITHYROID DRUGS:

1. Inhibits trapping of Iodide- thiouracil, iodine, carbimazole .

2. Iodine or Iodide: inhibit release of thyroid hormone.
3. Beta blockers: Decrease peripheral conversion of T4 to T3.
4. Radioactive Iodine: destroy overactive thyroid tissue.

THYROID FUNCTION TESTS

HYPOTHYROIDISM HYPERTHYROIDISM
serum T4 decrease increase

serum TSH Primary

hypothyroidism increase decrease
Secondary hypothyroidism decrease

Protein Bound Iodine decrease increase

Radioactive Iodine Uptake decrease increase

Serum Cholesterol increase decrease

Blood Sugar decrease increase

 The parathyroid glands, which lie behind the thyroid, manufacture the hormone
parathyroid, which plays a role in regulating your body's level of the minerals
calcium and phosphorus.

The parathyroid glands are four or more small glands, about the size of a grain of
rice, located on the posterior surface (back side) of the thyroid gland. The parathyroid
glands are named for their proximity to the thyroid but serve a completely different role
than the thyroid gland. They are quite easily recognizable from the thyroid as they have
densely packed cells, in contrast with the follicle structure of the thyroid. However, at
surgery, they are harder to differentiate from the thyroid or fat.

In the histological sense, they distinguish themselves from the thyroid gland, as they
contain two types of cells:[2]
Name Staining Quantity Size Function

parathyroid chief cells darker many smaller manufacture PTH (see below).

oxyphil cells lighter few larger function unknown.[3]

Physiology

The major function of the parathyroid glands is to maintain the body's calcium
level within a very narrow range, so that the nervous and muscular systems can
function properly.

When blood calcium levels drop below a certain point, calcium-sensing receptors
in the parathyroid gland are activated to release hormone into the blood.

Parathyroid hormone (PTH, also known as parathormone) is a small protein that

takes part in the control of calcium and phosphate homeostasis, as well as bone
physiology. Parathyroid hormone has effects antagonistic to those of calcitonin. PTH
increases blood calcium levels by stimulating osteoclasts to break down bone and
release calcium. PTH also increases gastrointestinal calcium absorption by activating
vitamin D, and promotes calcium conservation (reabsorption) by the kidneys. PTH
affects the perception of well being and absence of PTH can be associated with feeling
of fatigue and anxiety.

Calcitonin

Calcitonin is a 32-amino acid linear polypeptide hormone that is produced in

humans primarily by the parafollicular cells (also known as C-cells) of the thyroid, and in
many other animals in the ultimobranchial body. It acts to reduce blood calcium (Ca2+),
opposing the effects of parathyroid hormone (PTH). It has been found in fish, reptiles,
birds, and mammals. Its importance in humans has not been as well established as its
importance in other animals, as its function is usually not significant in the regulation of
normal calcium homeostasis

ACTION OF CALCITONIN

• Bone mineral metabolism:

- Protect against calcium loss from skeleton during periods of calcium

mobilization, such as pregnancy and, especially, lactation

• Serum calcium level regulation

- Prevent postprandial hypercalcemia resulting from absorption of Ca2+ from

foods during a meal
- Vitamin D regulation

• A satiety hormone:

- May have CNS action involving the regulation of feeding and appetite

PATHOPHYSIOLOGY OF NON-TOXIC MULTINODULAR GOITER

 PRECIPITATING
FACTOR: PREDISPOSING
Iodine deficiency FACTOR:
Poor Age
socioeconomic Female
status heredity

TSH synthesis

T3 and T4

TGSH

Dysphagia
Cell Hoarness of voice
multiplication and Palpable lumps
hyperplasia

Total ultrasou
Multinodular
Thyroidect
omy
non-toxic goiter nd

VII. DIAGNOSTIC PROCEDURE DONE TO THE PATIENT

Date Received: August 16, 2010

Time Received: 4:00 p.m

Date Released: August 16, 2010

Time Released: 4:00 p.m

HEMATOLOGY RESULT

Complete Blood Count (CBC)

The most commonly performed blood test is the complete blood count, which is a
basic component of cellular components of blood (RBC, WBC, and platelets).
Automated machine perform this test in less than one minute on a small drop of blood.
The CBC is supplemented in most instances by examination of blood cells under a
microscope.

The CBC determines the number of red blood cells and the amount of
hemoglobin in the blood. In addition, the size of red blood cells is usually assessed and
can alert laboratory workers to the presence of abnormally shaped red blood cells
(which may then be further characterized by microscopic examination). Abnormal red
blood cells may be fragmented or shaped like tear drops, crescents needles, or a
variety of other forms. Knowing the specific shape or size of red blood cells can help a
doctor diagnosed a particular cause of anemia. For example, sickle shaped cells are
characteristic of sickle cell disease, small cells containing insufficient amount of
hemoglobin may signal iron deficiency anemia and large oval cell suggest anemia due
to folic acid or vitamin B12 deficiency (pernicious anemia).

After putting together the information about number, size, and shape of red blood
cells, a doctor might order additional tests to evaluate the cause of an anemia. These
include tests for increased red blood cell fragility, abnormal types of hemoglobin, and
the quantities of certain other substances contain within red blood cells.

The CBC also determines the numbers of white blood cells. The specific type of
white blood cell can be counted (differential white blood cell count) when a doctor needs
more detailed information on a person’s condition. If the total number of white blood
cells or the number of one of the specific types of white blood cells is above or below
normal, the doctor can examine these cells under a microscope. The microscopic
examination can identify features that are characteristic of certain diseases. For
example, large number of white blood cells that have a very immature appearance
(blasts) may suggest leukemia (cancer of the white blood cells).

Platelets are usually counted as a part of CBC. The number of platelets is an important
measure of the blood’s protective mechanism for stopping (clotting). A high number of
platelets (thrombocytosis or thrombocypenia) can lead to blood clots in small blood
vessels, especially those in the heart or brain.

Reference:

The Merck Manual of Medical Information by Mark H. Beers M.D., 2nd Home Edition pp.
888-889

PARAMETERS RESULT NORMAL Interpretation Analysis

VALUES
Hemoglobin 124 gm/L 120-180 Normal -hemoglobin is
- To detect within a
anemia in a normal level
client with provides
bleeding after proper
trauma or oxygenation of
surgery the cell
Hematocrit .376 0.370-0.540 Normal -the
- Measures the percentage of
percentage of red blood cells
red blood cell in a total blood
in the total volume is
blood volume within a
 normal range
9
Leukocyte 5.8x10 /L 4.6-10.0 Normal -the number of
- Determines leukocyte
the number of count is within
circulating a normal
WBCs per range for
cubic defense to
millimeter of microorganism
whole blood
DIFFERENTIAL
COUNT .62 .60-.70 Normal -0.62 means
Segmenter that they
- type of mature made up 62%
white blood of the WBCs
cell you had in
your system
when you
were tested.

.35 .20-.40 Normal -indicates no

presence of
Lymphocytes viral
-A small white blood infections.
cell (leukocyte) that
plays a large role in
defending the body
against disease,
responsible for
immune responses.

306x109/L 150-450 Normal -no active

bleeding and
Platelet Count can prevent
- Important hemorrhage.
measure of
the blood’s
protective
mechanism for
stopping
bleeding
(clotting)
-

URINALYSIS

Urinalysis can be used to detect and measure the level of variety of substances
in the urine, including protein, glucose, ketones, blood and other substances. This test
use a thin strip of plastic (dipstick) impregnated with chemicals that react with
substances in the urine and change color. Sometimes the test results are confirmed
with more sophisticated and accurate laboratory analysis of the urine. The urine is
examined under a microscope to check for the presence of the red and white blood
cells. Crystals, casts.

Protein: Protein in the urine (proteinuria) can usually be detected with dipstick. Protein
may appear constantly or only intermittently on the urine, depending on the cause.
Proteinuria is usually a sign of kidney disorders, but it may occur normally after
strenuous exercise such as marathon running.

Glucose: Glucose in the urine (glucosuria) can be accurately detected by dipstick. The
most common cause of glucose in the urine is diabetes mellitus. If glucose continues to
appear in the urine while glucose levels in the blood are normal, impaired reabsorption
of glucose by the kidney tubules (renal glucosuria) is the cause of glucosuria.
Ketones: Ketones in the urine (ketonuria) can be detected by dipstick. Ketones are
formed when body breaks down fat. Starvation, uncontrolled diabetes mellitus, and
occasionally alcohol intoxication can produce ketones in the urine.

Blood: Blood in the urine are (hematuria) is detectable by dipstick and confirmed by
viewing urine with a microscope and other tests. Sometimes the urine contains enough
blood to be visible, making the urine appear red or brown.

Nitrates: Nitrates in the urine are (nitrituria) is detectable by dipstick and confirmed by
viewing urine with a microscope and other tests. Sometimes the urine contains enough
blood to be visible, making the urine appear red or brown.

Leukocyte Esterase: Leukocyte esterase (an enzyme found in certain white blood
cells). In the urine can be detected by dipstick. Leukocyte esterase is a sign of
inflammation, which is most commonly caused by UT.

Acidity: The acidity of urine is measured by dipstick. Certain foods and metabolic
disorders may change the acidity of the urine.

Concentration: The concentration of the urine (also called the osmolality or specific
gravity) may be important in diagnosing abnormal kidney function. The kidneys lose
their capacity to concentrate urine at an early stage of a disorder that leads to kidney
failure. In one special test, a person drinks no water or other fluids for 12-14 hours; in
other, a person receives an injection of antidiuretic hormone. Afterward, urine
concentration is measured. Normally, either test should make the urine highly
concentrated. However, in certain kidney disorders (such as nephrogenic diabetes
insipidus) the urine cannot be concentrated even though other kidney functions are
normal.

Sediment: Sediment in urine can be examined under a microscope to provide

information about a possible kidney or urinary tract disorder. Normally, urine contains a
small number of cells and other debris shed from inside of the urinary tract. A person
who has kidney or urinary tract disorder usually sheds more cells, which form a
sediment if the urine is centrifuge or allowed to settle.
Urine cultures: Urine cultures, in which bacteria are grown in a urine sample in a
laboratory, are perform to diagnose a urinary tract infection. The sample of urine must
be obtained by the clean-catch method. Other methods to obtain an uncontaminated
urine sample include passing a catheter through the urethra into the bladder or inserting
a needle through the abdominal wall into the bladder (suprapubic needle aspiration).

URINALYSIS CELLS CHEMICAL TEST

Color: Yellow RBC: 0-1/hpf Albumin: negative

Transparency: Clear Pus Cells: 0-1 hpf Sugar: Negative
Reaction: 5.0 Squamous Cells: few
Specific Gravity: 1.020 Bacteria: (-)

RADIOLOGY
Ultrasound (Sonogram)

Ultrasound uses high-frequency sound waves to look at organs and structures

inside the body. Health care professionals use them to view the heart, blood vessels,
kidneys, liver and other organs. During pregnancy, doctors use ultrasound tests to
examine the fetus. Unlike x-rays, ultrasound does not involve exposure to radiation.

During an ultrasound test, a special technician or doctor moves a device called a

transducer over part of your body. The transducer sends out sound waves, which
bounce off the tissues inside your body. The transducer also captures the waves that
bounce back. Images are created from these sound waves.

Xray

X-rays are a form of electromagnetic radiation, just like visible light. In a health care
setting, a machines sends are individual x-ray particles, called photons. These particles
pass through the body. A computer or special film is used to record the images that are
created.

Structures that are dense (such as bone) will block most of the x-ray particles, and will
appear white. Metal and contrast media (special dye used to highlight areas of the
body) will also appear white. Structures containing air will be black, and muscle, fat, and
fluid will appear as shades of gray.

Examination Thyroid
Right Lobe 4.5x1.1 x1.9 cm
Isthmus 0.1 cm
Left Lobe 4x1.0x1.8 cm

Both lobes and isthmus are normal in size with smooth contour and homogenous
parenchyma.

Three lesions are noted in the right lobe:

c) Two small thin walled cystic, anechoic lesion are noted in the mid aspect of
the right lobe with transverse diameter of 0.4 cm
d) Complex mass in the right inferior pole, predominantly cystic with a 0.60 cm-
echogenic focus in its superior aspect. The lesion measure
0.67x0.74x0.61cm.
No focal/diffuse solid or cystic lesions in the left lobe and isthmus.

Impression:
- Normal sized Thyroid Gland
- Cystic and complex nodules, RIGHT

IMMUNULOGY-SEROLOGY-ENDOCRINE REPORT
TSH test

The TSH test is often the test of choice for evaluating thyroid function and/or symptoms
of hyper- or hypothyroidism. It is frequently ordered along with or preceding a T4 test.
Other thyroid tests that may be ordered include a T3 test and thyroid antibodies (if
autoimmune-related thyroid disease is suspected).

TSH testing is used to:

• diagnose a thyroid disorder in a person with symptoms,

• screen newborns for an underactive thyroid,

• monitor thyroid replacement therapy in people with hypothyroidism

• diagnose and monitor female infertility problems,

• help evaluate the function of the pituitary gland (occasionally), and

• screen adults for thyroid disorders, although expert opinions vary on who can
benefit from screening and at what age to begin.

Examination Result Normal Values Interpretation

TSH 1.89 0.27-4.20 Normal
Free T3 3.47 2.02-4.43 Normal
Free T4 1.21 0.93-1.71 Normal

VDRL TEST

This test is used to diagnose syphilis. Syphilis is a highly treatable infection. In

addition to screening individuals with signs and symptoms of sexually transmitted
diseases, syphilis screening is a routine part of prenatal care during pregnancy. Several
states also require screening for syphilis prior to obtaining a marriage license.
 A negative test is normal and means that no antibodies to syphilis have been
detected. The screening test is most likely be positive in secondary and latent syphilis.
During primary and tertiary syphilis this test may be falsely negative.

A positive test result may mean you have syphilis. If the test is positive, the next
step is to confirm the results with an FTA-ABS test, which is a more specific syphilis
test.

Some conditions may cause a false positive test, including:

• HIV
• Lyme disease
• Certain types of pneumonia
• Malaria
• Systemic lupus erythematosus

Hepatitis B surface antigen (HBsAg). This is the first test to show a positive
result with acute hepatitis B infection. The level of the antigen rises before symptoms
begin and then returns to normal when the jaundice disappears. A person is considered
to be a carrier of hepatitis B if this antigen persists in the blood 6 months after the initial
infection. In rare cases, a person with hepatitis B who was initially a carrier of the
disease may eventually become a noncarrier and thus have lifelong immunity (that is,
he or she may be a "late seroconverter" of surface antigen).

Antibody to HBsAg (anti-HBs). The body makes this antibody to fight the viral
infection. Its presence usually indicates immunity against hepatitis B (the person has
previously had hepatitis B, recovered, and is now immune, or has been vaccinated
against hepatitis B and is now immune.) People who have a positive test result for this
antibody will not develop a hepatitis B infection again. Hepatitis B immune globulin
(HBIG) becomes detectable about 6 months after an acute hepatitis B infection and will
remain in the blood for life, although its level will decrease over many years. To prevent
hepatitis B, doctors inject super-concentrated antibody HBIG into people who have
been exposed to the disease.
 VDRL NON REACTIVE
HBs Ag Screening NON REACTIVE
HBs Ag (titer) Patient control
Hbe Patient control

MEDICAL MANAGEMENT:

This part of the case study explain different management ordered by the
physician during the patient’s hospitalization.

Intravenous fluid:

• D5LR @1 liter x 8 @ 32gtts/min (pre-op)

• PLR @ 1 liter x 8 KVO (intra-op)

Pharmacologic theraphy:

• Cefazolin 500 mg/IV q8 for 2 more doses

• Tramadol 50mg/cap PO q8hrs PRN only for severe pain

• Diclofenac 75mg/IV q8hrs x 3 doses

• Mefenamic Acid 500 mg/tab PO q6 hrs

• Cefuroxime 500 mg/tab q8 hrs

• Calcium carbonate 500mg/ tab BID

• Levothyroxine 500mg I tab once a day (given at OPD follow-up dated August 25, 2010)

SURGICAL MANAGEMENT:

Date of Operation: August 17, 2010

Type of Operation: Total Thyroidectomy

Time of Transfer from surgical ward to OR: 8am

Time of Transfer from PACU to surgical ward: 5pm

Pre-operative Care:

The goal of pre-operative for client with Non-toxic Multi Nodular Goiter before
surgery that Mrs. X was undergone preparation includes the following:

• Secured an informed consent by an immediate family member.

• Completed pre-operative checklist.

• Checked vital signs

• Pre-operative medicine given

 • Check electrocardiogram

• Instruct client on how to perform DBCT exercises and how to support the neck in
the past operation when coughing and moving.

• Monitor intake and output.

• For laboratory work up as follows:

 CP Clearance

 Urinalysis

 Hematology Test

 Ultrasound

 TSH Test

INTRAOPERATIVE CARE:

Anesthetic Record:

• On general anesthesia (oxygen Isoflurane)

• Monitored vital signs

POST-OPERATIVE:

The goal of post-operative for client with Non-toxic Multi Nodular Goiter after
surgery that Mrs. X includes the following:

 Vital signs monitor every 15 minutes for the 1st hour, 30 minutes for
the 2nd hour and every hour for the succeeding hours.

 Stabilized the patient’s ABC.

  Administered oxygen

 Monitor Intake and Output.

 Changing dressing aseptically as ordered.

 Position Semi- Fowler’s with head, neck, and shoulders erect.

 Monitor surgical site for bleeding and edema.

 Have tracheostomy set, oxygen and suction available at the

bedside.

 Assess for recurrent laryngeal nerve damage.

 Ask client to speak every hour.

 Limit client talking and assess for level of horseness. Mild

horseness is normal. This is due to intubation during of anesthesia
severe hoarseness indicates laryngeal nerve damage. Notify the
physician.

 Monitor for signs of hypocalcemia and tetany. This may be due to

trauma to parathyroid.

 Keep calcium gluconate readily available for tetany at

bedside.

 Monitor blood pressure. To assess for blood positiveTrousseau’s

sign (carpal spasm) which indicate hypocalcemia. (Compression of the
brachial artery with BP cuff for 3 minutes is done to assess for
Trousseau’s sign).

 Patients teaching after thyroidectomy include the following:

 Support head with interlaced fingers when getting up from

bed to prevent hyperextension of the neck.
  Start range of motion exercise of the neck 3 to 4 days after
discharge.

 Massage incision site with coconut oil, once healing occurs.

To minimize scarring.

 Have regular follow-up case.

DISCHARGE PLANNING

Patient may go home as ordered dated August 18, 2010 and was ordered to have OPD
follow-up a week after discharge.

Medications- Patient is for discharge, with the following take home medicine such as:

• Cefuroxime 500 mg I tab every 8 hours for 5 days

• Mefenamic acid 500mg every 6 hours
• Calcium carbonate 500mg I tab twice a day
Instruct the patient to religiously take the ordered medications at the right time, dosage,
and frequency.

Exercise - Total thyroidectomy actually requires time to recover. It is advised to have 4 to 6

weeks duration time for recovery. Once home, it is possible to tire more easily than usual to
begin with, so it is important to take it easy. Avoid straining at the affected area. Strenuous
exercise and lifting should be also avoided. Light exercise such as walking, deep breathing
and coughing exercise are recommended. Normal activities, including returning to work, can
usually be resumed after about a week.
Treatment - Multinodular Non-toxic Goiter disease usually is treated by removing the thyroid
gland. Now that the patient had her thyroid gland removed, the rest is up to her. It is important to
rest and let the body recover after surgery. Consequently, to prevent other complications, she
must have her lifestyle and diet modified.

Health Teaching - Explain to patient what to expect afterwards. As the anesthetic wears off,
there is likely to be some pain. The anesthetist will prescribe painkillers. Suffering from pain can
slow down recovery, so it's important to discuss any pain with the doctors or nurses.

 On discharge, patient must advise about caring for the stitches, hygiene and bathing,
and will arrange an outpatient appointment for the stitches to be removed, if necessary.
Some people will have dissolvable stitches, which do not need to be removed.
 Instruct patient to comply with the take home medications that would be given by her
physician. Remind her to complete the full course of the antibiotic treatment.
 Encourage patient to do the recommended light exercises such as walking. Avoid doing
strenuous activities which could slow down his recovery.
 Encourage him to comply with the dietary modifications; moderate the intake of iodine
rich food to prevent the occurrence of serious post-total thyroidectomy side-effects.
 Explain to patient to refer for unusual signs and symptoms of any untoward feelings
immediately regarding to her condition.

OPD Follow-up – Remind patients that regular check-ups are important to ensure that the
patient condition is constantly monitored by the doctor. If any of the following symptoms are
noted, he should contact her doctor:

• the wounds start to bleed

• wound become more painful, red, inflamed or swollen

• the abdomen swells

• pain is not relieved by the prescribed painkillers
• a fever develops.
These could be signs of an infection that may need to be treated with antibiotics
Diet- In time, patients who have suffered total thyroidectomy are exposed to a high risk of
developing osteoporosis, and other bone diseases due to lack of calcium in the bone as well as
in the blood. In order to prevent the occurrence of serious post- total thyroidectomy
complications, operated patients need to make drastic lifestyle and dietary changes. The patient
was ordered to take high protein foods for faster tissue repair and instructed on Diet as
tolerated. People who had thyroid removal surgery are advised to eat smaller meals.
Considering the fact that the metabolism is affected due to absence of thyroid gland and its
hormone that helps our body to regulate metabolism. Operated patients also need to take
vitamin and mineral supplements and artificial hormone for the replacement of the hormones
came from thyroid gland that aids the metabolism.

Spiritual- Provides emotional support coming from family. Encouraged the patient to participate
in the community services to promote social supportive relationship.