Thyroid Approach

– Thyroid Physical Exam –

  • WIPE, blah blah 🙂
  • “Take vital signs”
  • Position: sitting
  • Proper exposure: of the neck
  1. General inspection of the pt:
    • Appearance: lethargic \ restless
    • Body built: Over \ under wt
    • Clothing: over \ under dressed
    • Voice: hoarseness
  2. Hands\arms:
    • Hands: temperature, dry\sweaty, muscle wasting, palmar erythema
    • Nails: oncholysis, acropachy
    • Fine tremor
    • Pulse: rate\rhythm, collapsing pulsethyroid 3
    • “Measure BP”
    • Proximal myopathy
    • Pemberton sign
  3. Head\face:
    • Hair: loss\thin hair, loss of outer 1\3 of eyebrow
    • Facial puffiness
  4. Eyes:
    • Periorbital edema, thyroid stare\exophthalmos
    • Conjunctiva: redness\inflamed (chemosis)
    • Lid retraction (sclera visible above iris)
    • Lid lag (+ do “H” formation + ask about diplopia)
  5. Neck:
    • Inspection: obvious masses, scars, skin changes
    • Swallow test + ask pt to stick their tongue out
    • Palpate: thyroid, LN, trachea
    • Auscultate: over each lobe for bruit
  6. Legs:
    • Proximal myopathy
    • Pretibial myxedema
    • Reflexes

 


– Differential Diagnosis of Neck Nodule –

  • Thyroid
  • Thyroglossal duct cyst
  • Branchial cyst
  • Sebaceous cyst
  • Dermoid cyst
  • Lymphoma
  • Lymphadenopathy

 

– Investigations –

thyroid 1

 

– Management –

  • Based on FNA results -> Bethesda system:
    1. Non-diagnostic -> repeat FNA + US
    2. Benign -> F\U w\ periodic US
    3. Atypia of undetermined significance -> repeat FNA in 3 months
    4. Suspicious for follicular\Hurthle cell neoplasm -> either total or hemi thyroidectomy
    5. Suspicious for malignancy (usually papillary ca) -> total thyroidectomy
    6. Malignant -> total thyroidectomy

 

– Complications of Thyroidectomy –

  • Recurrent laryngeal nerve injury
  • Hypoparathyroidism
  • Hypothyroidism
  • Bleeding\hematoma (compressing airway)
  • Infection

 

– Types of Malignant Thyroid Cancers –

  • Papillary (most common type)
  • Follicular
  • Medullary (associated with MEN syndromes)
  • Anaplastic (worst prognosis)

 

– Thyroid Blood Supply –

  • Superior thyroid artery -> external carotid artery
  • Inferior thyroid artery -> thyrocervical trunk
  • Thyroid ima artery -> aorta (variant)

 thyroid 2

 


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