Sandra presonte with an enlargement in hor neck. Please take ahistory se se ~ introduction and rapport wll - age and occupation wd => Details of lump in neck - size, shape, consistency, fixation, tenderness, pulsatile = when did you first notice it ? (6/12 ago) - has it changed size or shape ? (slowly enlarging) - do you have any other lumpe in your neck or eleewhere ? Signs of obstruction - difficulty swallowing ? - difficulty breathing ? ~ developed a wheeze ? - change in voice ? ‘Thyrnid specific questians - have you noticed any change in weight ? ~ how has you appetite been ? ~have you noticed any change in bowel habit ? (frequency, consistency, blood, mucus) - which do you prefer: hot or cold temperatures ” How many blankets do you use in winter ? ~ have you noticed any changes in the volume of menstrual bleeding ? - being feeling tired and run-down ? - fever or recent URTI ? (thyroiditis - no) Specific for hyperthyroidism ~ chest pain or abnormal heart beats tremor (yes) ~ iitable and anxiety (yes) - double vision, sore red eyes, watery, appearance of eyes (Graves") Specific to hypothyroidism: - confused, difficult to concentrate, slowing of thoughts - dry skin and hair - muscle cramps - probleme with hearing - delayed puberty, infertility - swelling of ankles Risk factors for hypothyroidism ~ family history - past Hx of goitre (puberty, pregnancy) - exposure to iodine/radiatiowXRT + dmge (e.g amiodarone, contrast, lithium, thiazidee) = neck surgery = location of birth (Eastern Europe has high incidence of hypothyroidism) ~ past medical Hx (no history neck surgery, or thyroid disease), Fx insignificant, Social Hx... - meds: none smoking: nil ETOH: social allergies: noneWhat is the list of differential diagnoses in a pationt with a neck lump 7 + goitre - thyroid adenoma/cyst ~ thyroid cancer = thyroglossal duct cyst (smooth midline mass; moves poking tongue & swallowing) - Ivmphadenopathy of iugular chain - other: sebaceous cyst, lipoma, cystic hygroma, brachial cyst Whot features are important to determine about the mass ? - site, size, shape, surface characteristics - fixation (superficial/deep) - consistency, thuctuance, pulsatility, transilumanability ~ temperature ~ bruit - lymphadenopathy, surrounding skin (e.g rash, vessels) - complications e.g obstruction of other structures (Pemberton's sign, wheeze, dyspnoea) .../1 ‘What are the possible causes of a goitre ? - Graves’ disease = toxic muttinodular goitre - subacute thyroiditis, + Hasimoto’s thyroiditis - physiological (e.g puberty, pregnancy) ~ iodine deficiency non tonia oimplo thyroid hyperplasia ‘=> may be colloid goitre, multinodular goitre, diffuse goitre ‘What investigations are suitable to determine the cause of this goitre 7 - TFT: TSH. T4/T3 + thyroid autoantibodies - muclear uptake scan of thyroid ~ ENA of lump / biopsy ECG - FBE, lipids, ESR, U&Es, blood sugars - Ultrasound of neck. CXR What are the complications associated with the development of a goitre ‘? = cosmetic ~ haemorrhage (sudden pain) = fibrosis caleification ~ compression of trachea (dyspnoea, wheeze) - compression of recurrent laryngeal nerve (hoarse voice) = impairment of venous return of SVC (Pemberton’s sign) How may a goitre may managed despite treatment of specific cause ? - excision of excess glands or cyst (must leave 5-8¢ minimum to maintain function) (cosmetic, signs of compression, hormone secreting, MNG, risk of Ca.) aim to remove goitrogens, replace iodine deficiency, amalll dozes of thyroxine