Transcript pertinent negative pertinent positive

GROUP 1
CLINICOPATHOLOGIC
CONFERENCE
GENERAL DATA
Y.S., 71 year-old female, married,
housewife, Filipino, Roman Catholic from
Dumaguete who sought consult for the
first time.
CHIEF COMPLAINT
 Difficulty Breathing
HISTORY OF PRESENT ILLNESS
 The patient claims to have known “goiter” for around 15
years (enlarged bilateral anterior neck mass).
 15years PTC, patient claimed to have palpated an
anterior neck mass which she says firm and 1 peso coinsized on the RIGHT side of her neck. Since she did not
feel any other symptoms, she did consult with any
physician nor did she take any medications. The mass
grew slightly larger in size, over the course of 15 years
without any associated symptoms.
 3 mos PTC, patient noted that although the “goiter“
already affected both sides of her ant.neck, there was
also a separate, slightly fixed mass that was also coinsized on the lower Right lateral area of her neck. No
consult was done and the mass by this time seemed to
have suddenly increased in size but continued to be nonpainful.
 4 weeks PTC, patient started noticing some difficulty
swallowing solid foods although there is no pain. Her
voice would be “breathy“ and sometimes frankly hoarse.
In fact, it was continously hoarse for the past 6 days. She
finally sought consult at the OPD of a tertiary hospital
and a FNAB of the mass was ordered. A few days later,
while waiting for the biopsy results, she experienced
sudden dyspnea while carrying a heavy load of laundry at
home. She was then rushed by her children to the
nearest hospital.
PAST HISTORY
 No history of hypertension or asthma.The
patient suspects that she is diabetic but has
never been worked up. No current intake of
medications. No history of other medical
procedures or hospitalizations
PERSONAL AND SOCIAL HISTORY
 Non-smoker and occasionally drinks “tuba“.
She is a housewife and a laundrywoman. She
has 6 children, all grown.
FAMILY MEDICAL HISTORY
 (+) “goiter“ in maternal grandmother,
2 aunts and sister
 (+) “stroke“ and diabetes – father
(now deceased)
REVIEW OF SYSTEM
PERTINENT NEGATIVE
(-) fever
(-) malaise
(-) weight loss
PERTINENT POSITIVE
(+) slight dysphagia
(+) chronic unproductive cough
(+)anorexia/appetite loss
(-) cachexia
(-) abdominal pain
(-) palpitations
(+)stridor
(+)slight chest pain
(-) heat or cold intolerance
PYSICAL EXAMINATION
 VITAL SIGNS:
 BP = 148/90 mmHg
 HR = 110 bpm
 RR = 30‘s
 Temp. = 35.4 °C
 Pulse Oximetry = 92-94%
 The patient‘s skin is damp and slightly cook. She is
diaphoretic and stridorous, in respiratory distress; she
cannot tolerate a supine postion and must sit upright and
lean forward in order to breathe properly. She is no in
pain.
 OTOSCOPY: both tympanic membranes intact, with
minimak cerumen in the Right ear canal
 ANT. RHINOSCOPY: no significant findings; (+) nevus on
the Left nasal ala
 ORAL CAVITY: no lesions, tonsils are unenlarged;
multiple carious mandibular teeth; maxillary alveolus is
edentolous
 POSTERIOR RHINOSCOPY and INDIRECT LARYNGOSCOPY:
the patient could not tolerate these exams
 NECK EXAMINATION:
 There is a large and hard anterior neck mas,
seemingly larger on the Right side, but the Left
anterior neck is also enlarged. The mass is
nontender, hard, fixed to underlying structures,
moves only very slightly with deglutition. The
isthmus is also enlarged. The overlying skin is
smooth, brown, with no ulcerations, and the
mass is slightly fixed to the skin on the Right side
(biopsy site). The trachea can no longer ne
palpated. There is a possible enlarged cervical
node on C5 level of the Right neck, but it seems
continuous with the anterior neck mass. It is also
hard and fixed.
COURSE IN THE ER
 The patient stayed in the ER for 3 hours for neck
soft tissue lateral and AP views x-ray. Afterwhich,
she started deteriorating. It noted that she had
to really exert in order to breathe; stridor
worsens; she became drowsy and suddenly
turned cyanotic, her 02 saturation dropping to 40
%. The airway team was called and she was
intubated using a smaller sized ETT, as the
anesthesiologist had a difficult time inserting a
size 7.0 ET. Her 02 sat, increased to 80-84% and
remained there.
COURSE IN THE ER
 Her family was then informed that an emergency
tracheostomy and debulking of the mass was
being contemplated. Her children wanted to
have tha whole mass removed during the
operation but were told by the resident that the
patient was unstable to undergo such an
extensive operation. The tracheostomy was done
with difficulty and a part of the mass was sent for
rush histopath exam. The patient was
transferred to ICU but succumbed a few days
later due to pulmonary complications.
LAB RESULTS
 FNAB REPORT
 Bloody aspirate
 HISTOPATHOLOGIC REPORT
 Grossly, the tissue fragments were tan-white and
fleshy.
ANATOMY