Examination of the Thyroid Gland

History Ask patient: ● ● ● ● presenting with swilling or not Painful swilling ( indicate inflammation ) ex : all types of thyroiditis (Hashimoto’s thyroidits , riedel thyroiditis , de Quervain’s thyroiditis ) Progression swilling (if increase or decrease or stable ) Pursue symptoms ( dyspnea may be due to 1-position related 2-effort related , dysphasia) ▪ ● ● it can occur in benign or malignant Change in voice tone Symptom of function ( hyper or hypo ) ▪ If Hypo ( cold in tolerance , weight gain , dyspnea , constipation , lethargy and fatigue, loss of appetite , hair loss ,dryness , swelling of LM and in female change in the menstrual cycle or problem of fertility ) ▪ If hyper ( heat in toralence , palpitation , weight loss , diarrhea , anxiety , swatting , hair loss , female change in the menstrual cycle ) examination ● ● ● ● Expusre upper chest- patient on setting position hand shaking to se swatting , dry or tremor check redial pulse if normal or rapid check for graves disease late eyes sign: ▪ see eys if exopthalmos or not ( normally cant see sclera above and below the iris ) ▪ lid retraction if the superior and inferior limps is visible its exopthalmos ▪ lid lag ( make the patient fixed his hed and move your finger from up downward ) normally upper eyelid keep cover the iris (sclera is not visible ) ▪ opthalmoplegia : normally no wrinkling of extra oracular muscles ( cranial nerve test) positive if double vision or cant see your finger ▪ proptosis : is protrusion of the eyeball. Check the thyroid Inspection ● ● Make patient look upward Comment on swilling (size , shape , number , skin redness , special character ) ● ● ● ● Make patient swallow (see swilling move with swallowing or not ) You should specify the swilling place ( anterior triangle or posterior triangle ) The swilling Medline or lateral to the midline The swilling is in the ( left , right side or bilateral ) ▪ ● NB: if one side larger than the other one exclude defuse enlargement , if one site beggar than the other site describe each side swilling (size , shape , number , skin redness , special character ) Protrusion of the tong to exclude thyroglosal cyct Palpation ● ● ● ● ● ● Slight flexion position – posterior to the patient on setting position Make patient flex to one by your hand side to examine the other site Make patient swallow to find the mass if you cant localize it Palpate the mass and comment on ( consents , tecure , firm , soft , homogenous or not) You have to comment on the edge ( well define , smooth define , ill define , no define ) specially inferior edge ( indicate retostenal extension ) Comment on all cervical lymph node ( all from posterior in setting position ) both site Lymph node--- superficial deep by contraction of muscle the will be more prominent deep by contraction of muscle the will disappear Lypoma --- fluctiuation 5-10 cm side by side but if small between 2 fingers and push from above and see if fingers separated. Attachment to muscle by put muscle in action From front Auscultation: bruit sound in hyperthyrodism Percuction: direct on clavicle to chick retosternal. Tracheal diveation: finger in the sternal notch DDx Goiter: Dffiuse: butterfly shape Physiological: pupirety and pregnancy Ttt: only observation Gravis diseas: eye sign, hyperthyroidism, elevated T3 +T4, decrease TSH, antithyroglobuline , antimicrosomal antibody, Ttt antithyroid medication. if fail radioactive iodine ablation or total thyroidectomy Thyroditis: Hashimoto Thyroditis: hyper then hypothyroidism, painful, high antibody Ttt: supportive🡪non-steroidal anti-inflamatory, replacemint in hypothyroidism, surgery only in pressure symptoms De quervain thyroiditis: viral, autoimmune, Ttt supportive riedel's thyroiditis: fibrosis, hard gland, pressure symptoms Suppurative thyroiditis: bacterial Ttt: IV antibiotic, drainage Solitary thyroid nodule: Toxic: Ultrasound and isotope for localization Ttt: euthyroid state to prevent thyroid stormnb with anesthesia by : Anti-thyroid drugs B-blocker lugol's iodine hemithyroid ectomy Non-toxic: Cyst: aspiration 3 times. Is recurrence memithyroidectomy Adenomas Follicular : By FNA we cannot differentiate between Follicular Adenoma and Follicular carcinoma because it shows the cell not invasion. Ttt: hemithyroidectomy 🡪 sent to pathology 🡪 if benign that’s enough. but if carcinoma 🡪 total thyroidectomy Hurthil cell:??????????????????? Carcinoma Papillary, Follicular, Hurthil cell 🡪 all ttt totalthyroidectomy Chance of hemithyroidectomy only in papillary🡪 less than 5cm, no capsular invasion, Medullary: calcitonin is the marker Sporadic: Familial: 1-sporadic 2-multible endocrine neoplasia{MEN}: type 1 + 2 Multinodular: Toxic: Ttt: euthyroid state to prevent thyroid stormnb with anesthesia by : Anti-thyroid drugs B-blocker lugol's iodine then surgery:…….?? Non-toxic: Thyroid hyperplasia Ex: Iodine deficiency Hypo or euthyroid Indication foe sugery: Cosmetic Change in nodule ++size Hemorage Pain Pressure symptoms Ttt: total thyroidectomy or near total thyroidectomy Sub total not used because of recurrece risk Malignancy Papillary {most common}: if LN involved: total thyroidectomy + modefid radical neck dissection Follicular: spread by blood🡪 bone and lung 🡪 may need radiation tratment Hurthil cell: ………….. Medullary: total thyroidectomy 🡪 monitoring by calcetonin level Lymphoma: chemothrapy Anaplastic: palliative chemo + radio NB: thyroid storm: stress🡪epi and norepiniphrin🡪 increase effect of thyroid hormone Medullary carc