CLINICAL DIAGNOSIS OF THYROID DISORDERS Reynaldo O. Joson, M.D.

1992

INTRODUCTION
Thyroid disorders are very common in the Philippines. They are so common that practically all physicians will every now and then be confronted with a patient with a thyroid problem. For these reasons it is recommended that all physicians !now at least how to arrive to a clinical dia"nosis of a thyroid disorder. The phrase #clinical dia"nosis$ is %sed here to mean the %tili&ation of history and physical e'amination in arrivin" to a dia"nosis. (ltho%"h there are other dia"nostic proced%res which may be done to eval%ate patients with a possible thyroid problem this pro"ram will be limited to clinical dia"nosis. F%rthermore it will be limited to eval%ation of patients witho%t a history of previo%s treatment to their thyroid "land. This pro"ram is desi"ned to be a practical theoretical co%rse on how to "o abo%t eval%atin" patients with a possible thyroid disorder )%st based on history and physical e'amination. It disc%ssed the proper %tili&ation of the methods of clinical eval%ation* the identification of patients with and witho%t thyroid disorders* the nomenclat%re of thyroid diseases* the clinical classification of "oiters* the physical si"ns of thyroid mali"nancy* and lastly the clinical dia"nosis of patients with thyroid disorders.

OBJECTIVES Upon completion of this pro"ram the %ser is e'pected to be able to+ ,. Utili&e properly the two basic methods of clinical eval%ation in patients with a possible thyroid problem. -. Determine which patients have and do not have a thyroid disorder. .. Cite the nomenclat%re of thyroid disorders. /. 0'plain the clinical classification of "oiters. 1. 0n%merate the physical si"ns of thyroid mali"nancy. 2. 3a!e a lo"ical clinical dia"nosis of patients with thyroid disorders.

RECOMMENDED PREPARATIONS 4efore "oin" thro%"h this pro"ram the %ser sho%ld have a basic bac!"ro%nd !nowled"e of the anatomy physiolo"y and patholo"y of the thyroid "lands. 5e also m%st !now the f%ndamental principles in the dia"nostic process. The %ser is also advised to st%dy the followin" "lossary before before "oin" thro%"h the pro"ram+ ,. Thyroid patient 6 any patient presentin" with a possible act%al or obvio%s thyroid problem. -. Thyroid disorder 7 thyroid disease or problem. .. 8oiter 6 ori"inally %sed to mean a beni"n enlar"ement of the thyroid "land* may be %sed loosely to mean any thyroid disorder. I. 30T5OD9 OF C:INIC(: 0;(:U(TION OF T5<ROID P(TI0NT9 There are two methods in the clinical eval%ation of thyroid patients. These are history and physical e'amination. (ltho%"h these two methods are complimentary to each other in thyroid patients clinical e'aminations plays a more important role in the clinical dia"nosis. (. C5I0F CO3P:(INT The clinical eval%ation of a thyroid patient starts with the physician in=%irin" on what the problem of the patient is or what is the reason for the medical cons%ltation. ( Filipino thyroid patient will %s%ally point to his>her nec! while at the same time %tterin" any of the followin" %s%al sentences or phrases+ ,. I thin! I have a "oiter. -. I was told I have a "oiter. .. I have a l%mp here in the nec!. /. I have this feelin" of obstr%ction in my nec!. I may have a "oiter. 4. P5<9IC(: 0?(3IN(TION Once the physician "ets the c%e that the chief complaint of the patient is a possible thyroid problem he sho%ld ri"ht away start an e'amination of the patient@s nec!. 5e can contin%e as!in" =%estions while he performs the physical e'amination. The physician positioned in front of the patient first inspects the patient@s nec!. 5e loo!s for an incisional scar that may si"nify previo%s operative treatment. 5e also loo!s for obvio%s paratracheal nod%le and enlar"ement that may si"nify a thyroid disorder. (fter inspection the physician then positions himself at the bac! of the seated patient to start the nec! palpation. 5e first identifies the position of the trachea. 5e then places the - nd .rd and /th fin"ers of both hands alon" the vertical str%ct%re of the trachea. The patient is now as!ed to swallow. (s the patient swallows the physician initially tries to feel for any enlar"ed thyroid lobes or for any thyroid nod%les. ( mass in the paratracheal area that moves with de"l%tition is a thyroid disorder %ntil proven otherwise. In the presence of abnormalities the physician st%dies and describes them in term of symmetry si&e location consistency mobility and tenderness. (fter palpatin" the paratracheal area to eval%ate the thyroid "land the physician then palpates the lateral nec! for any enlar"ed lymph nodes.

(fter completion of the nec! e'amination the physician co%nts the p%lse rate. D%rin" this time that the physician is e'aminin" and tal!in" to the patient he sho%ld loo! for other si"ns that may s%""est thyroid disorder. 9pecifically he sho%ld loo! for e'ophthalmos* hoarseness of voice* and a distant mass that may be a metastatic thyroid cancer. Th%s at the very least the physical e'amination of a thyroid patient sho%ld incl%de the followin"+ ,. Inspection of the nec! -. Palpation of the paratracheal area .. Palpation of the lateral nec! /. P%lse rate 1. :oo!in" for si"ns that may s%""est thyroid disorder s%ch as e'ophthalmos hoarseness of voice and a distant mass that may be metastatic cancer. C. IN7D0PT5 INT0R;I0A Once a thyroid disorder is detected or s%spected thro%"h physical e'amination an in7depth interviewin" or history ta!in" may now be %nderta!en In patients who have no previo%s treatment the followin" are some pertinent =%estions that may be as!ed+ ,. Ahen was the thyroid disorder first notedB CNot when did it startBD -. If there is hoarseness of voice when did it occ%rB .. If there is a re"ional or distant mass noticeable by the patient when was it first discoveredB /. Is there any accompanyin" painB The physician sho%ld avoid as!in" irrelevant =%estions or =%estions that see! answers that are considered not reliable cl%es for thyroid disorder s%ch as e'cessive sweatin" easy fati"abiliaty and e'cessive appetite. (ltho%"h this is not part of this pro"ram in patients with a history of previo%s treatment in=%iries have to be made re"ardin" laboratory e'aminations medications operative records and biopsy res%lts.

REVIEW QUESTIONS I Direction+ 9%pply the appropriate answers. (. Name the two methods %tili&ed in the clinical eval%ation of thyroid patients. ,. -. 4. 0n%merate in a lo"ical se=%ence the minim%m physical e'amination that a physician m%st do to be able to arrive to a clinical dia"nosis in a thyroid patients .. /. 1. 2. E. C. Name at least five characteristics of a thyroid nod%le that m%st be decribed d%rin" physical e'amination. F. G. ,H. ,,. ,-. Direction+ Indicate which of the followin" statements are tr%e CTD and which are false CFD by circlin" the appropriate letter. T T T T T F F F F F ,.. In thyroid patients physical e'amination plays a more important role than history in the clinical dia"nosis. ,/. The best position that the physician m%st ass%me when palpatin" a thyroid patient@s nec! is in front of the patient. ,1. (s!in" the patient to swallow is part of the physician@s techni=%e in palpatin" the thyroid patient@s nec!. ,2. ( history of e'cessive sweatin" is an important information that m%st be loo!ed for d%rin" history ta!in" of a thyroid patient. ,E. In7depth history ta!in" sho%ld be done before physical e'amination in a thyroid patient.

Please check your answers on page 14.

II.

ID0NTIFIC(TION OF P(TI0NT9 AIT5 ( T5<ROID DI9ORD0R9 (fter the physical e'amination and history ta!in" the physician sho%ld decide whether a thyroid disorder is present or not. ( thyroid disorder is considered not to be present if the thyroid "land is not palpable* of no thyroid nod%le is palpated* if the p%lse rate is less than GH>min%te* and if there is no re"ional or distant mass to s%""est a metastatic cancer from an occ%lt primary thyroid cancer. Normally a thyroid "land is not normally palpable on the nec!. There is however a sit%ation wherein a normal thyroid "land can be clinically palpable on the nec!. This is in very thin patients with minimal s%bc%taneo%s tiss%es and thinned7o%t strap m%scles. There are also sit%ations in which the thyroid "land is diff%se and sli"htly enlar"ed and yet a thyroid disorder is not considered to be present. Physiolo"ic "oiters are e'amples of these sit%ations. These are seen in adolescent and pre"nant or postpart%m thyroid patients. ( thyroid disorder is considered to be present in the followin" conditions+ ,. If the patient manifests si"ns of hyperthyroidism. -. If the patient manifests si"ns of hypothyroidism. .. If the thyroid "land is abnormally enlar"ed. /. If the thyroid "land contains a nod%le or m%ltiple nod%les. 1. If the patient has a re"ional or distant mass considered to be metastatic cancer from an occ%lt primary thyroid cancer.

REVIEW QUESTIONS II DIR0CTION+ 9%pply the appropriate answers+ (. 0n%merate the fo%r physical e'amination findin"s Cpositive as well as ne"ative findin"sD on which to base yo%r decision that a thyroid disorder is not present. ,. -. .. /. 4. Name three sit%ations in which the thyroid "land may be palpable b%t yet a thyroid disorder is not considered to be present. 1. 2. E. C. Name five sit%ations in which a thyroid disorder is considered to be present. F. G ,H. ,,. ,-. Please check your answers in page 14.

III.

NO30NC:(TUR0 OF T5<ROID DI9ORD0R9I Ahen ma!in" a dia"nosis a physician m%st !now the name of the disease In the clinical dia"nosis of thyroid patients !nowled"e of the nomenclat%re of thyroid disorders is of "reat help. ( practical nomenclat%re is presented below+ ,. CO::OID (D0NO3(TOU9 8OIT0R ,.,. Diff%se colloid "oiter ,.-. Colloid cyst ,... Colloid adenomato%s "oiter ,./. 3%ltiple colloid adenomato%s "oiter -. 5<P0RT5<ROIDI93 .. T5<ROID C(NC0R ..,. Papillary carcinoma ..-. Follic%lar carcinoma .... (naplastic carcinoma ../. 3ed%llary carcinoma /. T5<ROIDITI9 /.,. (c%te thyroiditis /.-. Thyroid abscess /... Chronic thyroiditis 1. 5<POT5<ROIDI93 2. FO::ICU:(R (D0NO3( The above nomenclat%re is deemed practical for the folowin" reasons+ ,. It is a simplified nomenclat%re. For e'ample patients with hypothyroidism can present with diff%se or nod%lar "oiter. They can present with or witho%t e'ophthalmos. Instead of the traditional terms s%ch as diff%se to'ic "oiter nod%lar to'ic "oiter 8rave@s disease and Pl%mmer@s disease the word #hyperthyroidism$ as a clinical dia"nosis is s%fficient. -. It has a clinical basis. It is descriptive of the physical findin"s. For e'ample a cystic mass which most li!ely contains colloid fl%id is a colloid cyst. ( diff%se "oiter witho%t hyperthyroidism and si"ns of mali"nancy is a diff%se colloid "oiter. ( colloid adenomato%s "oiter with m%ltiple nod%les is a m%ltiple colloid adenomato%s "oiter. .. There are no clearc%t clinical cl%es for a dia"nosis of follic%lar adenoma. Th%s no clinical dia"nosis of follic%lar adenoma sho%ld be made.

REVIEW QUESTIONS III DIR0CTION+ 9%pply the appropriate answers. (. 0n%merate the five ma)or types of thyroid disorders. ,. -. .. /. 1. 4. 0n%merate the fo%r types of thyroid cancer. 2. E. F. G. C. 0n%merate the fo%r clinical forms of colloid adenomato%s "oiter. ,H. ,,. ,-. ,.. D. 0n%merate the three clinical forms of thyroiditis. ,/. ,1. ,2. Please check your answers on page 14.

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C:INIC(: C:(99IFIC(TION OF 8OIT0R9I There is a clinical classification of "oiters which is very helpf%l in arrivin" to a clinical dia"nosis. The classification consists of combinin" the physiolo"ic and anatomic abnormalitis of the thyroid "land. The clinical classification is as follows+ ,. Diff%se to'ic "oiter -. Diff%se nonto'ic hoiter .. Nod%lar to'ic "oiter /. Nod%lar nonto'ic "oiter The nod%lar "oiters can f%rther be s%bdivided into the followin"+ .., Uninod%lar to'ic "oiter ..- 3%ltinod%lar to'ic "oiter /., Uninod%lar nonto'ic "oiter /.- 3%ltinod%lar nonto'ic "oiter ( diff%se "oiter is said to be present if all the lobes of the thyroid "land are almost symmetrically enlar"ed and there are no discrete nod%les. If a lobe of the thyroid "land is smoothly enlar"ed Cdiff%sely witho%t discrete nod%le on palpationD the clinical classification is not a diff%se "oiter b%t a nod%lar "oiter. The first reason for a nod%lar classification is that there is only a %nilobar enlar"ement. The second reason is that s%ch a %nilobar enlar"ement %s%ally contains a nod%le within it. ( nod%lar "oiter is one that contains nod%le either sin"le or m%ltiple. ( to'ic "oiter is present if there are si"ns of hyperthyroidism. ( nonto'ic "oiter is present if there are no si"ns of hyperthyroidism. The patient is %s%ally e%thyroid* rarely is hypothyroidism present. ( practical r%le of th%mb to follow is that if the p%lse rate is less than GH>min%te then the "oiter that is palpably present is nonto'ic. If the p%lse rate is e=%al to or "reater than GH>min%te a hyperthyroidism has to be r%led o%t in the presence of a "oiter %sin" other data in the physical e'amination. It m%st be borne in mind that tachycardia may be present even in nonto'ic "oiter. 0ach of the cate"ories in the clinical classification of "oiter can be represented by several common and %ncommon thyroid diseases. If a patient is classified %nder a specific cate"ory then the differential dia"nosis will incl%de all the diseases listed %nder it. If there are common and %ncommon diseases %nder the said cate"ory then the more common disease is the more li!ely dia"nosis %nless there are ob)ective data to point to the less common diasese. 4elow is a tab%lation of the different thyroid diseases %nder each clinical classification of "oiters to"ether with their relative prevalence+ DIFFU90 TO?IC 8OIT0R 5yperthyroidism CcommonD DIFFU90 NONTO?IC 8OIT0R Diff%se colloid "oiter CcommonD Chronic thyroiditis Cnot commonD UNINODU:(R TO?IC 8OIT0R Cnot commonD 5yperthyroidism

3U:TINODU:(R TO?IC 8OIT0R Cnot commonD 5yperthyroidism UNINODU:(R NONTO?IC 8OIT0R Colloid cyst Cvery commonD Colloid adenomato%s nod%le Cvery commonD Thyroid cancer CcommonD Chronic thyroiditis Cnot commonD 3UT:INODU:(R NONTO?IC 8OIT0R 3%ltiple colloid adenomato%s "oiter Cvery commonD Thyroid cancer CcommonD Chronic thyroiditis Cnot commonD REVIEW QUESTIONS IV DIR0CTION+ 9%pply the appropriate answers 0n%merate the si' cate"ories in the clinical classification of "oiters that combine physiolo"ic and str%ct%ral abnormalities of the thyroid "land and "ive one common representative thyroid disease %nder each cate"ory+ ,. -. .. /. 1. 2. Please check your answers on page 15.

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P5<9IC(: 9I8N9 OF T5<ROID 3(:I8N(NC<I (s a r%le it is only in e%thyroid patients with thyroid nod%les or nod%lar "oiters that a thyroid mali"nancy can be incl%ded as one of the differential dia"noses. Thyroid nod%les on palpation may be cystic or solid. ( cystic thyroid nod%le is one that contains fl%id specifically colloid fl%id. ( solid thyroid nod%le is one that does not contain fl%id. (s a r%le it is only in solid nod%les that a thyroid mali"nancy can be incl%ded as one of the differential dia"noses. 9olid thyroid nod%les may be hard or not hard. (ltho%"h thyroid mali"nancies may present as hard and not hard solid the former consistency has a hi"her positive predictive val%e. 9olid thyroid nod%les may be fi'ed or mobile. Fi'ation comes in three forms. One is fi'ation to the tracheal fascia. (nother is fi'ation to overlyin" s!in and soft tiss%e. 9till another form is fi'ation to the prevertebral fascia as is %s%ally seen in anaplastic carcinomas. The presence of fi'ation of the thyroid nod%le sho%ld aro%se s%spicion of mali"nancy. In addition to the hardness and fi'ation of thyroid nod%les the other physical si"ns of thyroid mali"nancy are+ ,. 5oarseness of voice that is d%e to an involvement of the rec%rrent laryn"eal nerve. -. Nec! nodes especially on the side of the thyroid nod%le considered to be metastatic. .. Distant mass that is considered to be a metastatic lesion. (ny one si"n mentioned above if present is eno%"h "ro%nd to s%spect thyroid mali"nancy. REVIEW QUESTIONS V

DIR0CTION+ 9%pply the appropriate answers. 0n%merate five physical si"ns of thyroid mali"nancy. ,. -. .. /. 1. DIR0CTION+ T T F F Indicate which of the followin" statements are tr%e CTD and which are false CFD by circlin" the appropriate letter. 2. Thyroid mali"nancy sho%ld be one of the most probable differential dia"noses in diff%se "oiters. E. 3ali"nancy sho%ld be one of the most probable differential dia"noses in cystic thyroid nod%les.

Please check your answers on page 15.

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C:INIC(: DI(8NO9I9 OF T5<ROID DI9ORD0R9II

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( clinical dia"nosis of patients with thyroid disorders is an ed%cated "%ess that is derived based primarily on the ob)ective data obtained from the physical e'amination and secondarily on the prevalence of the diseases and statistical probabilities. The dia"nostic process is "reatly facilitated if the physician has obtained the followin" !nowled"e and s!ills+ ,. -. .. /. 1. Proper methods of clinical eval%ation. Identification of patients with and witho%t a thyroid disorder. The f%nctional nomenclat%re of thyroid disorders. The clinical classification of "oiters. The physical si"ns of thyroid mali"nancy.

4elow is a tab%lation showin" essential data obtained from a patient and the correspondin" clinical dia"nosis that sho%ld be made. Case , Case Case . Case / Case 1 Case 2 Case E D(T( Diff%se "oiter* PR J GH>min%te No si"ns of mali"nancy Diff%se "oiter* PR J GH>min%te No si"ns of mali"nancy 0'ophthalmos Diff%se "oiter* PR K GH>min%te No si"ns of mali"nancy 9olitary thyroid nod%le not hard solid PR J GH>min%te No si"ns of mali"nancy 9olitary thyroid nod%le cystic PR J GH>min%te No si"ns of mali"nancy 9olitary thyroid nod%le hard solid PR K GH>min%te 9olitary thyroid nod%le hard fi'ed solid PR K GH>min%te 9olitary thyroid nod%le not hard solid PR K GH>min%te 9!%ll mass lytic* no dyspha"ia no dyspnea 9olitary thyroid nod%le not hard solid PR K GH>min%te Ipsilateral nec! nodes 5%"e thyroid nod%le fi'ed to the prevertebral fascia with dyspha"ia and dyspnea PR J GH>min%te 3%ltiple thyroid nod%les C:INIC(: DI(8NO9I9 To r%le o%t hyperthyroidism before acceptin" diff%se colloid "oiter 5yperthyroidism with e'ophthalmos Diff%se colloid "oiter To r%le o%t hyperthyroidism before acceptin" colloid adenomato%s "oiter Colloid cyst> colloid adenomato%s nod%le Thyroid cancer most probably papillary by prevalence Thyroid cancer most probably papillary by prevalence Follic%lar carcinoma with s!%ll metastasis

Case F

Case G

Papillary carcinoma with nec! node metastasis (naplastic carcinoma

Case ,H

Case ,,

3%ltiple colloid adenomato%s "oiter

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Case ,-

PR K GH>min%te No si"ns of mali"nancy 3%ltiple thyroid nod%les PR J GH>min%te No si"ns of mali"nancy Nod%lar thyroid "land No discrete mass PR K GH>min%te No si"ns of mali"nancy Tender fl%ct%ant mass on the thyroid "land PR J GH>min%te No si"ns of mali"nancy Diff%se "oiter PR K GH>min%te 9hort obese stat%re with %n%s%ally slow body movements

To r%le o%t hyperthyroidism before acceptin" m%ltiple colloid adenomato%s "oiter Chronic thyroiditis

Case ,.

Case ,/

Thyroid abscess

Case ,1

To r%le o%t hypothyroidism

In the above tab%lation there are sit%ations in which clinical dia"nosis can be made with ease and certainty. There are also sit%ations in which the clinical dia"nosis is made with reservations. The latter sit%ations are enco%ntered primarily in those with a p%lse rate of GH>min%te or "reater and in which there are no reliable ob)ective data available to r%le o%t hyperthyroidism. These are seen in cases , / and ,-. (nother factor that contrib%tes to the e=%ivocal clinical dia"nosis is the rarity of the disease as seen in cases / ,- and ,1. In case 1 the clinical dia"nosis is colloid cyst> colloid adenomato%s nod%le. Oftentimes it is hard to differentiate the two clinical "ro%nd especially if the nod%le is small. 4oth can have the same consistency that is cystic beca%se both have fl%id content. It is only in a lar"e colloid cyst Cabo%t . cm or "reaterD that a confident dia"nosis can be made. In s%ch a lar"e si&e cyst there is more elbow room to displace the fl%id inside so as to "ive the dia"nosis away. There are certain thyroid diseases which cannot be made on clinical "ro%nds. One reason is beca%se of rarity that it sho%ld not be the primary dia"nosis. (n e'ample is med%llary thyroid carcinoma. (nother reason is that there are no clinical data stron" eno%"h to s%pport it. (n e'ample is follic%lar adenoma. ( solitary thyroid nod%le can be a follic%lar adenoma. 5owever since the characteristics of the nod%le of follic%lar adenoma are hard to differentiate from those of a colloid adenomato%s nod%le and since the latter thyroid disease is more common the latter dia"nosis is %s%ally made. ( m%ltinod%lar nonto'ic "oiter witho%t physical si"ns of mali"nancy can be a follic%lar carcinoma. 5owever a m%ltiple colloid adenomato%s "oiter is %s%ally "iven as a clinical dia"nosis beca%se it is the most common ca%se. It is only when there is a distant mass s%spected of metastasis that a dia"nosis of follic%lar carcinoma is made as is seen in Case F.

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REVIEW QUESTIONS VI DIR0CTION+ 8iven the clinical data in Col%mn ( ma!e a clinical dia"nosis and write it down on the space %nder Col%mn 4. Col%mn ( ,. Diff%se "oiter PR L ,-H>min%te e'ophthalmos no si"ns of mali"nancy -. 9olitary thyroid nod%le hard and fi'ed* PR L FH>min%te* No distant metastasis .. 9olitary thyroid nod%le cystic* PRLFH>min%te* No si"ns of mali"nancy /. 9olitary thyroid nod%le cystic* PRLFH>min%te* Collapse of vertebral bodies* No dyspnea 1. 9olitary thyroid nod%le not hard solid* PRLFH>min%te* Ipsilateral nec! nodes 2. 5%"e thyroid mass fi'ed* dyspha"ia dyspnea* PR L ,HH>min%te E. 3%ltiple thyroid nod%les* PRLFH>min%te* No si"ns of mali"nancy F. Nod%lar thyroid "land* No discreet mass* PR L EH>min%te G. Diff%se "oiter* PR L 2H>min%te* No si"ns of mali"nancy ,H. Diff%se "oiter* PR L ,-H>min%te* No si"ns of mali"nancy Please chec! yo%r answers on pa"e ,1 Col%mn 4 ,. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM -. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM .. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM /. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 1. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 2. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM E. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM F. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM G. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM ,H. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

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ANSWERS TO REVIEW QUESTIONS I. ,. -. .. /. 1. 2. E. F. G. ,H. ,,. ,-. ,.. ,/. ,1. ,2. ,E. II. ,. -. .. /. 1. 2. E. F. G. ,H. ,,. ,-. III. ,. -. .. /. 1. 2. E. F. G. ,H. ,,. ,-. ,.. ,/. ,1. ,2. Review =%estion I 5istory Physical e'amination Inspection of the nec! Palpation of the paratracheal area Palpation of the lateral nec! P%lse rate :oo!in" for other si"ns that will s%""est thyroid disorders 9i&e Consistency Fi'ation or mobility Tenderness location T F T F F Review =%estions II The thyroid "land is not palpable There is no palpable thyroid nod%le The p%lse rate is less than GH>min%te There is no re"ional or distant mass to s%""est metastatic cancer from an occ%lt primary thyroid cancer. ;ery thin patients Physiolo"ic "oiter d%rin" adolescence Physiolo"ic "oiter d%rin" pre"nancy If the patient manifest si"ns of hyperthyroidism If the patient manifest si"ns of hypothyroidism If the thyroid "land is abnormally enlar"ed If the thyroid "land contains a nod%le or m%ltiple nod%les If the patient has re"ional or distant mass considered to be metastatic cancer from an occ%lt primary thyroid cancer. Review =%estions III Colloid adenomato%s "oiter 5yperthyroidism 5ypothyroidism Thyroid cancer Thyroiditis Papillary carcinoma Follic%lar carcinoma (naplastic carcinoma 3ed%llary carcinoma Diff%se colloid "oiter Colloid cyst Colloid adenomato%s "oiter 3%ltiple colloid adenomato%s "oiter (c%te thyroiditis Thyroid abscess Chronic thyroiditis

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I. ,E. ,F. ,G. -H. -,.

Review =%estion I; Diff%se to'ic "oiter Diff%se nonto'ic "oiter Uninod%lar to'ic "oiter 3%ltinod%lar to'ic "oiter Uninod%lar nonto'ic "oiter

--. 3%ltinod%lar nonto'ic "oiter

7 hyperthyroidism 7 diff%se colloid "oiter 7 hyperthyroidism 7 hyperthyroidism 7 colloid adenomato%s "oiter 7 colloid cyst 7 thyroid cancer 7 Cany of theseD 7 m%ltiple colloid adenomato%s "oiter 7 Thyroid cancer 7 Chronic thyroiditis 7 Cany of the aboveD

II. -. .. /. 1. 2. E. F. I. -.. -/. -1. -2. -E. -F. -G. .H. .,. .-.

Review =%estions ; 5ard solid thyroid nod%le Fi'ed thyroid nod%le 5oarseness of voice Cervical lymph nodes considered to be metastatic Distant mass that is considered to be metastatic F F Review =%estions ;I hyperthyroidism thyroid cancer most probably papillary cancer Colloid cyst> colloid adenomato%s nod%le Follic%lar carcinoma Papillary carcinoma (naplastic carcinoma 3%ltiple colloid adenomato%s "oiter Chronic thyroiditis Diff%se colloid "oiter 5yperthyroidism R0F0R0NC09 ,. De8own 0: De8own R:+ 4edside Dia"nostic 0'amination. New <or! 3ac3illan P%blishin" Co. Inc. ,GE2. -. Delph 35 3annin" RT CedsD+ 3a)or@s Physical Dia"nosis. Eth 0dition. Philadelphia A.4. 9a%nders Co. ,G2F. .. Noson RO+ Thyroid 9%r"ical Diseases. Philippines ,GF2. /. Robbins 9:+ Patholo"y. .rd 0d. Philadelphia A4 9a%nders Co. ,G2E. 1. 9abiston DC Nr CedD+ Davis7Christopher Te'tboo! of 9%r"ery. The 4iolo"ical 4asis of 3odern 9%r"ical Practice. ,-the 0d. Philadelphia A4 9a%nders Co. ,GF,. 2. 9chwart& 9I+ Principles of 9%r"ery 1th 0d. New <or! 3c8raw75ill 4oo! Co. ,GFF.

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POST-TEST

I. DIR0CTION+

Indicate which of the followin" statement are tr%e CTD and which are false CFD by circlin" the appropriate letter.

T T T T T T T T T T T T T T T

F F F F F F F F F F F F F F F

,. In the clinical eval%ation of thyroid patients physical e'amination plays a more important role than history. -. ( mass in the paratracheal area that moves with de"l%tition is a thyroid disorder %ntil proven otherwise. .. ( patient with a diff%se "oiter with a history of e'cessive sweatin" and easy fati"ability and a p%lse rate of less than GH>min%te sho%ld be s%spected to have hyperthyroidism. /. ( thyroid disorder is considered not to be present if e'amination of the nec! and the rest of the body shows no abnormality and the p%lse rate is FH>min%te. 1. ( clinically palpable thyroid "land can be normal. 2. It is only in thyroid nod%les that a mali"nancy is incl%ded in the differential dia"nosis. E. ( cystic thyroid nod%le is beni"n %ntil proven otherwise. F. ( hard solid thyroid nod%le is mali"nant %ntil proven otherwise. G. 3ed%llary thyroid carcinoma is very rare in the Philippines. ,H. Nod%lar to'ic "oiter are rare compared to diff%se to'ic "oiter. ,,. ( nonto'ic "oiter is synonymo%s with e%thyroid "oiter. ,-. Chronic thyroiditis is not common in the Philippines. ,.. 5yperthyroiidsm can present as a diff%se as well as a nod%lar "oiter. ,/. Follic%lar (denoma and colloid adenomato%s nod%le are synonymo%s. ,1. ( p%lse rate of ,HH>min%te or "reater is patho"nomonic of to'ic "oiter.

II. DIR0CTION+ Choose the best answer by circlin" the appropriate letter. ,2. ( ,/ year old female presented with a solitary soft thyroid nod%le and m%ltiple ipsilateral nec! nodes. The p%lse rate was ,HH>min%te. Ahat is yo%r dia"nosisB a. Follic%lar carcinoma b. Papillary carcinoma c. Colloid adenomato%s nod%le and t%berc%lo%s lymphadenopathy d. Uninod%lar to'ic "oiter

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,E. ( 1H year old female presented with a solitary thyroid nod%le / cm in si&e and cystic. There were no nec! nodes nor masses in other parts of the body. The p%lse rate was FH>min%te. Ahat is yo%r dia"nosisB a. Papillary carcinoma b. Follic%lar carcinoma c. Colloid cyst d. Colloid adenomato%s "oiter e. Nod%lar to'ic "oiter ,F. ( /H year old female presented with m%ltiple nod%les on the thyroid "land. The nod%les were of different consistencies. 9ome were firm. 9ome were cystic. The p%lse rate was FH>min%te. There were no nec! nodes. There was no mass in other parts of the body. Ahat is yo%r dia"nosisB a. Follic%lar carcinoma b. Papillary carcinoma c. 3%ltiple colloid adenomato%s "oiter d. 3%ltinod%lar nonto'ic "oiter e. Chronic thyroiditis ,G. ( -- year old female presents with a diff%se "oiter and a p%lse rate of ,-H>min%te. There was no e'ophthalmos. There was a palpable lymph node in the ri"ht s%bmandib%lar area. Ahat is yo%r dia"nosisB a. 5yperthyroidism b. 8rave@s disease c. Diff%se to'ic "oiter d. Diff%se nonto'ic "oiter e. Papillary carcinoma -H. ( /H year old female presented with a - cm hard thyroid nod%le to"ether with a parieto7occipital mass which on '7ray shows lytic chan"es on the s!%ll. The p%lse rate was ,HH>min%te. Ahat is yo%r dia"nosisB a. (naplastic carcinoma b. Follic%lar carcinoma c. 3ed%llary carcinoma d. Papillary carcinoma e. Nod%lar to'ic "oiter -,. ( ,G year old female presented with a h%"e movable diff%sely enlar"ed thyroid "land. The p%lse rate was FH>min%te. There were no nec! nodes nor masses in other parts of the body. a. Diff%se non7to'ic "oiter b. Diff%se colloid "oiter c. Iodine7deficiency "oiter d. Physiolo"ic "oiter --. ( /H year old female presented with a hard fi'ed nod%le on the ri"ht lobe of her thyroid "land. The p%lse rate is ,HH>min%te. There were no nec! nodes nor other masses in other parts of the body. Ahat is yo%r dia"nosisB a. Papillary carcinoma b. Follic%lar carcinoma c. (naplastic carcinoma d. Nod%lar to'ic "oiter

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-.. ( 2H year old female presented with an F7cm thyroid mass which was firm non7tender and fi'ed. The mass moves minimally with de"l%tition. The p%lse rate was ,HH>min. The patient was dyspneic. Ahat is yo%r dia"nosisB a. Papillary carcinoma b. Follic%lar carcinoma c. (naplastic carcinoma d. 3ed%llary carcinoma e. Nod%lar to'ic "oiter -/. ( ,/ year old female presented with a solitary nod%le on the left lobe of her thyroid "land. The nod%le was - cm in si&e soft movable and not tender. There were no nec! nodes nor masses in other parts of the body. The p%lse rate was FH>min. Ahat is yo%r dia"nosisB a. Follic%lar adenoma b. Colloid adenomato%s c. Papillary thyroid carcinoma d. Nod%lar non7to'ic "oiter -1. ( 1H year old female presented with m%ltiple thyroid nod%le of different consistencies. The p%lse rate was ,HHH>min. There was a clavic%lar t%mor which on '7ray shows lytic chan"es. Ahat is yo%r dia"nosisB a. 3%ltiple colloid adenomato%s "oiter with bone cancer b. (naplastic carcinoma c. Papillary carcinoma d. Follic%lar carcinoma e. 3ed%llary carcinoma Please chec! yo%r answers on pa"e ,G.

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ANSWERS TO POST TEST I. ,. T -. T .. F /. T 1. T 2. T E. T F. T G. T ,H. T ,,. F ,-. T ,.. T ,/. F ,1. F II. ,2. 4 ,E. C ,F. C ,G. ( -H. 4 -,. 4 --. ( -.. C -/. 4 -1. D

R0CO330ND0D FO::OA7UP

(fter completin" this self7instr%ctional pro"ram the %ser is advised to apply what he learns from this pro"ram in the clinics. 5e is enco%ra"ed to disc%ss this pro"ram with his peers and his teachers. (fter a clinical dia"nosis thyroid f%nction tests needle eval%ation and other dia"nostic proced%res may have to be done. If the %ser is interested in the f%rther mana"ement of a thyroid patient after clinical dia"nosis he can read on the different dia"nostic proced%re.

(4OUT T50 (UT5OR

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Dr. Reynaldo O. Noson is presently an assistant professor at the Department of 9%r"ery of the University of the Philippines colle"e of 3edicine. 5e is also presently the actin" chief of the Division of 5ead and Nec! 4reast 0sopha"%s and 9oft Tiss%e 9%r"ery of the Department of 9%r"ery at the Philippine 8eneral 5ospital. From ,GFF to ,GG, he was the Director of the U.P. Post"rad%ate Instit%te of 3edicine. 5e is a diplomate of the Philippine 4oard of 9%r"ery. In ,GF2 he wrote a boo! entitled # Thyroid 9%r"ical Diseases # which is widely read by s%r"eons in the Philippines. 5e has so far written ei"ht boo!s and man%als. 5e has twenty fo%r p%blished research articles as senior a%thor as of ,GG,. 5e obtained a master@s de"ree in hospital administration in ,GG, and he is the assistant medical director of the 3anila Doctor@s 5ospital from ,GFF %p to the present.

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