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 coin- sized 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 coin- sized 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 non- painful.  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 NEGATIVEPERTINENT POSITIVE (-) fever(+) slight dysphagia (-) malaise(+) chronic unproductive cough (-) weight loss(+)anorexia/appetite loss (-) cachexia(+)stridor (-) abdominal pain(+)slight chest pain (-) palpitations (-) 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