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B3 GenSurg SGD 3 Thyroid
B3 GenSurg SGD 3 Thyroid
Montenegro
THYROID SGD
A 48 year old female came in for consult because of anterior neck mass. She noted the mass to be
enlarging since 2019. There are no associated symptoms such as hoarseness, dysphagia or difficulty
breathing. No consultation was done in Benguet province.
1. What information will you ask the patient that would help arrive at a clinical diagnosis?
Discuss.
HPI
● Ask symptoms related to hyper- and hypothyroidism to narrow down possible causes of thyroid
enlargement
○ Hyperthyroidism
■ Palpitations, tremors, fatigue/weakness, heat intolerance, increase in sweating,
hair thinning/loss, weight loss, diarrhea, anxiety
○ Hypothyroidism
■ Cold intolerance, weight gain, brittle hair, constipation, dry skin, mood changes
such as depression or forgetfulness, puffiness in the face
● Ask symptoms that may attribute it to a possible malignancy (although it has been enlarging for
some time already, most likely it is benign)
○ Pain
○ Any swelling felt in the neck (palpable lymph nodes)
Secondary Hx
● ROS
○ If the patient is exhibiting other pulmonary symptoms such as DOB
○ If there is any symptom of bone pain
■ These are the two most common areas (Bone and Lungs) where thyroid
cancers could metastasize and if the said symptoms are present, then we may
consider a malignancy in the thyroid gland.
○ Hoarseness, progressive dysphagia
Tertiary
● Past history
○ Birth and developmental history
○ Childhood illness
○ Adults illness
○ History of transfusion
○ Surgical procedures
○ Injuries
○ Allergies
○ Obstetric history and Gynecological history
■ It is important to ask the patient if she has any history of thyroid disorders that
was diagnosed from childhood to adulthood. In addition to this, the gynecologic
history of the patient should be asked because this would help us rule out
other differential diagnoses such as postpartum thyroiditis. Also we would want
to know if our patient is already in menopause. Furthermore, we would want to
know any history of cancer if we are considering a malignancy that may have
metastasized to the thyroid gland.
2. Describe the physical findings? What other essential data regarding the physical exam would
you ask?
PE: What other essential data regarding the physical exam would you ask?
PE (What other essential data re: the PE would you ask) hillary
- Important landmark if thyroid gland examination - cricoid cartilage
- Suspect malignancy if nodule is hard, gritty or nodules fixed to surrounding structures
such as trachea and strap muscles
- Examine cervical lymph nodes and posterior triangle nodes (lymphadenopathy)
Differential Diagnosis:
● The differential diagnosis in a patient presenting with a neck mass is extensive and varies with
the age of the patient at presentation.
● Neck masses that are not goiter may be congenital, inflammatory, or neoplastic disorders.
● Congenital neck masses are usually present at birth but may present at any age inflammatory
neck masses are most commonly due to infection, typically reactive viral
lymphadenopathy
● Neck masses that result from metastatic disease are predominantly related to metastatic
squamous cell carcinoma arising from the aerodigestive tract but may be due to
metastatic skin cancer
● Most important in differentiating nontoxic goiter from other causes of goiter is to exclude
Malignancy
○ This means thyroid cancers such as follicular thyroid carcinoma, medullary thyroid
carcinoma, papillary thyroid carcinoma, and thyroid lymphoma should be excluded
● Other cause of goiter that must be differentiated from nontoxic goiter include inflammatory
goiter
○ Hashimoto thyroiditis, De Quervain thyroiditis, and Riedle thyroiditis are important
inflammatory goiters that should be differentiated from nontoxic goiters.
4. Discuss the significant laboratory and ancillary tests that should be requested.
No single test can determine the complete thyroid function. It is therefore important to correlate each
finding with the patient’s clinical manifestations. According to Schwartz, in most patients that clinically
appear to be euthyroid, TSH is the only test necessary.
Severe iodine deficiency causes hypothyroidism. Mild and moderate iodine deficiencies
cause multifocal autonomous growth of thyroid, which results in hyperthyroidism.
CT scan
● Not routinely requested and usually indicated in obstructive/compressive symptoms,
extrathyroidal involvement, substernal extension and it serves as road map prior to operative
surgery
● Useful in large, fixed substernal goiters
● Used to delineate size and goiter extent
● Helpful in evaluating the extent of retrosternal extension and airway compression
● In diffuse and multinodular nontoxic goiter there is (+) retrosternal extension and in uninodular
nontoxic goiter retrosternal extension is unusual
FNAB
● Presence of nodule suspicious of cancer
● Preferably ultrasound guided
● Ultrasound parameters suggestive of malignancy in thyroid nodules (table)
5. How would you manage the case? What are possible complications of the procedure and how
should these be managed?
On thyroid scan:
● In 10 cold nodules → 1-2 malignant (20%)
● In 10 cancer - thyroid scan - how many will have a cold nodule - 8-9 cold nodules
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