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 pulse
   • “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

 

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– Differential Diagnosis of Neck Nodule –

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

 

– Investigations –

 

– 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)

 

 

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