Thyroid

Thyroid History

1. Age

Ask the complain. When say neck lump, ask to drink water.

Duration

2. Thyroid status

  • Weight loss despite good appetite
  • Sweating and heat intolerance
  • Diarrhoea
  • Palpitations
  • Weight gain despite poor appetite
  • Cold intolerance
  • Constipation
  • Lethargy and day time sleepiness

3. Compressive features

Respiratory difficulty specially when lying down

4. Malignant features

  • Recent rapid enlargement
  • Hoarseness of voice
  • Absent carotid pulse
  • Tracheal deviation

5. Use of Thyroxine or Carbimazole

Thyroid Examination

1.From front

Inspection

  • Lump in the anatomical location of thyroid.
  • {Discolouration (haemorrhage into a cyst).}
  • Scars (Recurrent)
  • Dilated veins.
  • Moves up with swallowing.

Take a general idea whether its a MNG or solitary nodule (rest of the gland normal), dominant nodule (rest of the gland enlarged),diffuse enlargement.

  • {Pemberton sign – Ask to raise hand and look either side. Look for dilated neck veins.} only if retrosternal extension.

Palpation

  • Palpate trachea.
  • Carotid pulse (Berry sign)
  • {Percuss} (only if RSE)
  • Retrosternal extension

2.From behind

  • Flex the neck slightly to relax strap muscles and investing fascia.
  • Palpate one lobe at a time.
  • Retrosternal extension.
  • Cervical lymphadenopathy.

3.General examination

To check thyroid status

  • Eye signs – 6 (Lid lag, Lid retraction, opthalmoplegia, exopthalmos, chemosis, loss of 2/3 of eyebrow)
  • Hand signs – 6 (sweating, tremors, pulse, palmar erythema, acropathy, numbness)
  • Leg – 2 (Pre-tibial myxoedema, Slow releasing jerks)

Presentation

I examined a

1. 50yr old lady with a MNG
2. No malignant features like cervical lymphadenopathy, Tracheal deviation and carotid pulse is present.
3. No compressive features like CL, TD and retrosternal extension.
4. On examination she is hyperthyroid.

Management of Thyrotoxicosis

  1. Pharmacological
    • Carbimazole
    • Propylthiouracil
  2. Surgical
    • Thyroidectomy
  3. Radiological
    • Radiothyroid ablation

Theory

Thy and BETHESDA are used to report FNAC

THY is from 1 to 5
BETHESDA is from 1 to 6
THY 3 is divided into Thy 3a and Thy 3f and corresponds to BETHESDA 3 and 4

Mx of THY 3 : Lobectomy (Excision biopsy) and send for histology. If malignant, Total thyroidectomy.

References

THY 3a and 3f – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716411/

BETHESDA – https://www.ncbi.nlm.nih.gov/pubmed/29091573