Surgery Clinical Demonstration: Thyroid

Question 1

General examination

Answer 1

• Sit

- Water

Question 2

History

Answer 2

1. PQRST
2. Hoarseness (Volume + Quality of voice): initial manifestation of thyroid diseases
3. Difficulty breathing
4. Dysphagia / Choking
5. Thyrotoxicosis symptoms
   - Palpitations
   - Weight loss
   - Tremor
   - Sweating
   - Heat intolerance
   - Diarrhoea
   - Oligomenorrhoea
6. Family history of Goitre / Thyroid disease

Question 3

Inspection

Answer 3

General condition

• Anxious
• Tremor
• Exophthalmos
• Lid retraction

Neck extended

1. Swelling
   - size
   - symmetry
   - location
   - localised / diffuse
   - upward movement when swallowing —> suggest thyroid nature
   - upward movement when protrude tongue —> Thyroglossal cyst
2. Symmetry
   - indicate Nodular / Diffuse
3. Mass
4. Dilated veins
5. Abnormal colour changes
6. Previous thyroidectomy / surgical scar

Question 4

Palpation

Answer 4

1. Swelling
   - Nodular / Diffuse / Dominant nodule
   - Location, Size, Shape, Surface, Consistency, Tenderness, Mobility / Fixation
   - Compare L/R
   - Lower border of swelling —> see if can get below gland when swallowing —> if cannot: **Retrosternal extension of goitre
   - **Pemberton’s sign —> facial congestion due to obstruction of SVC drainage
2. Cervical LN
3. Tracheal deviation

Question 5

Retrosternal goitre

Answer 5

1. Percussion
   - L/R paratracheal area —> ***Dullness in upper sternal area —> percuss till resonant to define lower border
   - usually extend towards one side behind sternum
2. Auscultation (use bell)
   - ***Diffuse thyrotoxic goitre / Graves’ disease —> Audible bruit

Question 6

Other examinations

Answer 6

Hyper:

• Thyroid acropachy (Graves’)
• Palmar erythema
• ***Pulse (High: Hyper, Low: Hypo)
• ***Restriction of eye movement (Graves’)
• ***Lid lag (Graves’)
• ***Pre-tibial myxedema (Graves’)
• Proximal myopathy
• AF

Hypo:

• Dry skin
• Pulse (High: Hyper, Low: Hypo)
• Hyporeflexia

Question 7

Pathology of Thyroid

Answer 7

Hyperthyroidism:

• Graves’ (Diffuse goitre, Exophthalmos, Lid retraction, Lid lag, Pre-tibial myxedema, Bruit)
• Toxic multinodular goitre
• Toxic adenoma

Goitre (Andre Tan):

• Diffuse goitre —> Graves’, Simple Non-toxic goitre, Lymphoma
• Multinodular goitre —> Toxic MNG, Hashimoto’s
• Solitary nodule —> Dominant nodule of MNG, Follicular adenoma, Follicular carcinoma, Cysts

Neoplasm:

• Follicular adenoma
• Follicular carcinoma
• Papillary carcinoma
• Anaplastic carcinoma
• Medullary carcinoma

Question 8

Investigations of Thyroid disease

Answer 8

1. TSH / T4 profile
2. Antibody
3. Blood tests
4. USG
   - Nodules
   - Doppler for increased vascularity
5. FNAC (malignancy)
6. CXR (deviation of trachea, retrosternal goitre)