Professional Documents
Culture Documents
RESIDENCE
• IODINE DEF ENDEMIC SIMPLE GOITER =
• Areas
• Near rocky mountains (e.g. Himalayas, Satpudas, Vindyas)
• Producing chalk/limestone (e.g. Derbyshire, Southern Ireland)
• As calcium is goitrogenic
• Low land where
• Soil lacks iodides
• Water supply comes from far away mountain ranges (e.g. Great Lakes of North America)
OCCUPATION
• Individuals working under stress & strain
SWELLING
• Onset, Duration, Rate of growth
• Same size for sometime or Very slow = SIMPLE GOITRE
• Extremely slow = COLLOID, MULTINODULAR, SOLITARY GOITRE
• Slow = PAPILLARY, FOLLICULAR CA
• Exist as lump in neck for many years before metastasising
• Fast = ANAPLASTIC CA
• Association w pain
• Worried, Stressed, Strained
• FEATURES OF THYROTOXICOSIS
• Sudden ↑ size + Pain in goiter = HAEMORRHAGE inside
• Sleep
• Sleepless night = 1° THYROTOXICOSIS
• Palpitations, Ectopic beats, Congestive cardiac failure = 2° THROTOXICOSIS
PAIN
• Painless = GOITRE
• Painful =
• INFLAMMATORY COND OF THYROID GLAND
• ANAPLASTIC CA
• Infiltrate surrounding structures & nerves
• Painless 1st , Painful in later stages = MALIGNANT DISEASES OF THYROID GLAND
PRESSURE EFFECTS
• Enlarged thyroid Press on
• Trachea Compress on trachea/Deviate trachea to one side DYSPNEA
• Symptom worse when neck flexed forwards/laterally
• As air rushes through narrowed trachea Whistling sound STRIDOR
• Oesophagus DYSPHAGIA – BUT NOT true dysphagia
• As oesophagus muscular tube – Pushed aside/Stretched easily - ∴ Rarely obstructed by thyroid gland
• Rather in 1st stage of deglutition thyroid gland moves up - ∴ Enlarged thyroid makes swallowing uncomfortable
• Recurrent laryngeal n HOARSENESS OF VOICE
SYMPTOMS OF 1° THROTOXICOSIS
• ENLARGEMENT OF THYROID GLAND NOT MUCH
• ∴ ONLY SYMPTOMS INDICATE PRESENCE OF DISEASE
• SLEEP
• Sleepless night
• WEIGHT
• LOSS OF WEIGHT
• Inspite of GOOD APPETITE
• TEMP
• Excessive sweating
• Heat intolerance
• Preference for cold
• CNS
• Excitability, Irritability, Tremor of hands, Weakness of muscles
• EYE
• Exopthalmos
• C/C – Starring/Protruding eyes, Difficulty in closing eye lids
• Diplopia/Double vision
• ETIO : Muscle weakness (i.e. ophthalmoplegia)
• Oedema/Swelling of conjunctiva (i.e. chemosis)
• Corneal ulceration Pain
• ETIO : Exposure keratitis
SYMPTOMS OF 2° THROTOXICOSIS
• LONG-STANDING MNG, SN MANIFESTATIONS K.A. 2° THROTOXICOSIS
• CVS
• Palpitations, Ectopic beats, Congestive cardiac failure
• Shape, Size
• Colour, Edges, Surf
• Impulse on coughing
• Movement w
• Respiration
• Deglutition
• Protrusion of tongue
• Peristalsis, Pressure effects, Pulsation
• Skin over swelling
• PALPATION
• Shape, Size
• Consistency, Edges, Extent, Surf, Temp, Tenderness
• Compressibility, Fluctuation, Fluid thrill, Mobility, Pulsatility, Reducibility, Translucency
• Impulse on coughing
• Fixity to overlying skin
• PERCUSSION
• AUSCULTATION
• MEASUREMENT
• STATE OF REGIONAL LN
• EXAMINATIONS PECULIAR TO THYROID GLAND DESCRIBED BELOW
INSPECTION
• METHOD
• Inspection in normal position
• Pizzillo’s method
• INDICATION : Obese, Short-necked
• PROC
• Place hands behind head
• Ask pt to push head backwards against clasped hands
• IMP : Improves inspection of goitre
• THYROID GLAND
• NOT obvious on inspection normally
• Seen ONLY when swollen
• RESULT
• Uniform thyroid swelling involving whole thyroid gland
• = COLLOID GOITRE, HASHIMOTO’S DISEASE, PHYSIOLOGICAL GOITRE
• Isolated nodules of different sizes in thyroid region
• = NODULAR GOITRE
D/D ON INSPECTION
• RETROSTERNAL GOITRE
• P on great veins at thoracic inlet DIL OF SUBCUTANEOUS V OVER UPPER ANT PART OF THORAX
• NOT POSSIBLE TO DETERMINE LOWER BORDER OF SWELLING ON DEGLUTITION
• Ask pt to raise both arms over head until they touch ears
• Maintain position for awhile
• CONGESTION OF FACE + DISTRESS
• Due to obstruction of great veins at thoracic inlet
• THYROGLOSSAL CYST
• MOVES UPWARDS ON DEGLUTITION
• MOVES UPWARDS W PROTRUSION OF TONGUE$
• THYROGLOSSAL FISTULA
• NEAR MIDLINE LITTLE BELOW HYOID BONE
METHODS OF PALPATION
METHOD 1 LAHEY’S METHOD
• PT • PURPOSE : Palpation of each lobe
• Sit on stool • CLINICIAN
• Slightly flex neck • Stand in front pt
• CLINICIAN • PALPATION OF LT LOBE
• Stand behind pt • Push thyroid gland to left
• PALPATION • From rt side
• Thumbs of both hands behind neck • By lt hand of clinician
• Other 4 fingers of each hand on each lobe & isthmus • Palpate w rt hand
• PALPATION OF CERVICAL LN
• IF SWELLING LOCALIZED
• SITUATION
• SHAPE, SIZE, EXTENT
• MOBILITY
• Fixity = CHR THYROIDITIS, MALIGNANT TUMOR
• TO GET BELOW THYROID GLAND
• AIM : To discard possibility of retrosternal extension
• PROC
• Ask pt to swallow Thyroid swelling moves up
• Clinician place index finger on lower border of thyroid gland
• Palpate for any extension downwards
• PULSATION/THRILL IN THYROID
• PRESSURE EFFECT
• PROC : Palpate trachea
• RESULT : Position of trachea
• KOCHER’S TEST
• PROC : Push slightly on lat lobe
• RESULT
• Stridor = ‘+’ KOCHER’S = OBSTRUCTED TRACHEA = CARCINOMA, MNG
• PROC
• Ask pts to raise hands above head
• Arms touching ears
• RESULT
• Engorgement of neck veins obvious = PEMBERTON’S SIGN = OBSTRUCTION TO MAJ VEINS IN THORAX
• PALPATION OF CERVICAL LN
• IMP IN MALIGNANCY OF THYROID
• Esp Papillary carcinoma of thyroid Early lymphatic metastasis Metastatic enlarged LN K.A. ABERRANT THYROID
PERCUSSION
• PROC
• Percuss over manubrium sterni
• AIM
• To exclude presence of retrosternal goiter