Thyroid HX EX PDF

Thyroid A goitre or goiter (Latin gutteria, struma), is a swelling in the thyroid gland. Goiter can be diffuse, nodule, or multinodular. Classification: 1. simple (non toxic): 2.toxic goitre:...

Thyroid A goitre or goiter (Latin gutteria, struma), is a swelling in the thyroid gland. Goiter can be diffuse, nodule, or multinodular. Classification: 1. simple (non toxic): 2.toxic goitre:  simple hyperplastic goitre (colloid).  diffuse (grave’s disease).  multinodular goitre.  Nodular  multinodular. 3.inflammatory: 4.autoimmune:  deQuervain’s thyroiditis (sub acute).  Hashimoto’s thyroiditis.  Riedel’s thyroiditis. 5.neoplastic goitre :  adenoma (benign).  papillary Ca (malignant).  follicular Ca.  anaplastic Ca.  medullary Ca. History Chief complain : anterior neck swelling for # duration(onset+site) Present illness : (5 groups) GroupA: description of the mass 1-first symptom the patient notice and how 2-progression 3-painful or painless 4-Extension 5-multiplicity :presence of other lump anywhere in the body GroupB: pressure symptoms 1-shortness of breath due to deviation or compression of trachea & the symptoms become worse if the neck flexed laterally or forward. If trachea is narrowed, a whistling sound (stridor) can be heard during inspiration. 2-difficulty in swallowing : Large swellings cause tugging sensation in the neck & rarely obstruct the esophagus. It is not true dysphasia, it is because the thyroid is pulled upward with the trachea during swallowing. |Page Group C: question determine whether hyper or hypo Hyperthyroidism Hypothyroidism 1.Metabolic symptoms: 1.Metabolic symptoms: -increase appetite Tiredness & weakness - weight loss. heat sensitivity Physical & mental lethargy. -heat intolerance. Always feels cold (pt like hot weather & dislike - excessive sweating cold weather). Wight gain but poor appetite. 2.CVS: 2.CVS: - palpitation. Breathlessness and ankle swelling indicate the - shortness of breath on exertion. onset of heart failure due to - extra systole & Atrial fibrillation. myxoedematous infiltration of the heart. - tiredness. *CVS symptoms are often the presenting symptoms of 2ry thyrotoxicosis. 3.Neurological: 3. Neurological : 1) nervousness Slow & unclear thoughts, speech, action. 2) irritability. Deep, hoarse voice. 3) insomnia ‫أرق‬ Hallucination, 4) depression. dementia (37yxedema madness). 5) Hyperesthesia Carpal tunnel syndrome. 6) headache 7) vertigo. 8) tremors of hands &tongue. 4. GIT: 4. GIT: mild diarrhea - Constipation. 5.Others.. 5.Others.. - oligomenorrhea/ amenorrhea. - Anemia. - wasting& weakness of small muscles of hand, - Menorrhagia. heavy or prolonged bleeding during your period shoulder& face - ↓sweating Group D: 1-any other swelling 2-change in voice (hoarseness of voice) : A very significant symptom because it may be caused by a paralysis of one of the recurrent laryngeal nerve i.e. the lump is a neoplastic Ca invading the nerve. Group E: Patient reaction : investigation 1-Blood thyroid function tests T3,T4,TSH T4 elevated =suggest hyperthyroidism TSH elevated = suggest hypothyroidism 2-imaging ultrasound : To know if the lump is cystic or solid & the general shape &outline of the gland 3- FNA : benefit in differentiation between follicular and papillary carcinoma |Page Note: FNA doesn’t differentiate whether the follicular mass is adenoma or carcinoma so we need to do histopathology if invasive=carcinoma ,not invasive =ad. 4- plain X-ray of the chest & thoracic inlet: Determine if there is tracheal displacement & compression. To see if there is a retrosternal extension of the gland 5- Indirect laryngoscope. (one of the complication of thyroid surgery is the injury to RLN; unilateral injury ‫اختناق‬ results in hoarseness of the voice, while bilateral injury results in suffocation. So the indirect laryngoscope before the surgery will tell if the injury occurred during or before). 5- ECG: In hypothyroidism: low electrical activity with small complexes. In hyperthyroidism: to confirm atrial fibrillation. Thyroid function test Biochemical Tests TSH (n 0.5–5 mU/L) FreeT4 (n 0.8-1.8 ng/dL) Total T4 (n 5.5-12.5 µg/dL) Total T3 (n70-200 ng/dL) Thyroglobulin (Tg) level Calcitonin Thyroid antibodies Thyroid Peroxidase antibodies (TPOab) Thyroglobulin (Tg) antibodies TSH receptor antibodies (TRAB)  Serum calcium. Notes:  24-hr radioactive iodine uptake (RAIU) is useful to distinguish hyperthyroidism from iatrogenic thyroid hormone synthesis (thyrotoxicosis factitia) and from thyroiditis.  An overactive thyroid shows increased uptake, whereas a normal underactive thyroid (iatrogenic thyroid ingestion, painless or subacute thyroiditis) shows normal or decreased uptake.  The RAIU results also vary with the etiology of the hyperthyroidism  Graves’ disease: increased homogeneous uptake  Multinodular goiter: increased heterogeneous uptake  Hot nodule: single focus of increased uptake  RAIU is also generally performed before the therapeutic administration of radioactive iodine to determine the appropriate dose. |Page  ‫راﺑﻂ ﺷﺮح د ﻓﺮات‬ https://youtu.be/TU9_4VfueKw? si=duzTQU4njKKobJcr Thyroid examination 1-neck  Inspection (4S+ 3 question) -Distended neck veins may indicate retrosternal extension  4S Site: exact position Size: Shape (Irregular, oval ,spherical) State of over lining skin ( redness ,discharge or Scar)  Ask the patient to swallow -if moved thyroid gland Because of the attachment of thyroid gland to the larynx , aswelling will always rise with deglutition unless the gland fixed by neoplastic infiltration or inflammation (riedl's thyroiditis) or scar from previous surgery  Ask the patient to protrude his tongue https://youtu.be/2JofSu3e8oI? -if its elevated then its thyroglossal cyst si=x6GFP_SkL1bHD4Xx https://youtu.be/mFfjJClx4fA? si=ObLDhdRzHIfKAkkF - Thyroglossal duct, (cyst) above or below hyoid. The duct should be obliterated just before birth, if it remains patent, cyst will form. The duct attached above at the foramen cecum Bellow at the cricoid cartilage -treatment surgically by removal of the duct (because of the risk of the fistula formation - Before you excise the cyst, you should do a very important investigation which is the isotope scan by I123 or Tc99, because sometimes the whole thyroid tissue presents within the cyst so you should eliminate this possibility. (there’s considerable percentage of fistula formation and infection). When you remove the cyst, you should remove the hyoid bone, otherwise you may have recurrence, the thyroglossal duct passes through the bony material of the hyoid bone. |Page   Ask the patient to elevate his hand pemberton's sign => retrosternal goitre when the patient lifts both arms as high as possible, venous congestion of the face & neck occurs after a few minutes if a retrosternal goitre is present.  Clinical note : swelling of thyroid gland and movement on swallowing The thyroid gland is invested in a sheath derived from the pretrachial fascia.this tethers the gland to the larynx and the trachea and explains why the thyroid gland follows the movements of the larynx in swallowing.this information is important because any pathologic neck swelling that is part of the thyroid gland will moved upward when the patient is asked to swallow.  Palpation 1-anterior (3T)  Temperature : use the dorsum of the hand  Tenderness  Tracheal deviation (We use index to palpate the ring of trachea if it is central or shifted :::in the suprasternal notch) 2-posterior ( use both your 2 thumb to press on occipital protuberance to tilt the head slightly forward ,the 2 index on the mandible ,use the palmar surface of the remaning finger to palpate ) a-both hands (both lobes) 1- define the lower edge of the lump to define retrosternal notch 2- ask the patient to swallow again if you can get below the mass ,this mean no retrosternal goiter