clinical diagnosis of thyroid disorders

Clinical Diagnosis of

Thyroid Disorders

Reynaldo O. Joson, MD1985;2001

Thyroid Disorders

Very common

in the

Philippines!

Clinical Diagnosis of

Thyroid Disorders

Reynaldo O. Joson, MD1985;2001

Clinical Diagnosis

Diagnosis based on

•History

•Physical Exam

Learning Objectives

•Proper utilization of methods of clinical evaluation

•Identification of patients with and without thyroid disorders

•Nomenclature of thyroid disorders

•Clinical classification of goiter

•Physical signs of thyroid cancer

Proper utilization of methods of clinical

evaluation

Clinical Diagnosis

Diagnosis based on

•History

•Physical Exam

Clinical Diagnosis

Thyroid Patients

Physical exam

more important than

history!

Clinical Diagnosis

Physical exam data

more reliable than

historical data!

Physical Examof

Thyroid Patients

Thyroid Patients Physical Exam•Inspection of neck

•Palpation of paratracheal area

•Palpation of lateral neck

•Pulse rate

•Looking for

•Exophthalmos

•Hoarseness of voice

•Distant mass

Low paratracheal mass that moves with deglutition

suspect thyroid

pathology!

Pulse Rate and Goiter

Less than 90/min

- nontoxic goiter

90/min and above

- to rule out toxic goiter

Hyperthyroidism Present

(+) Signs of hyperthyroidism

•Goiter

•Tachycardia

•Exophthalmos

•Bruit

•Tremor

Hypothyroidism Present

(+) Signs of hypothyroidism

•Goiter

•Dwarfism

•Slow body movements

Identification of Patients With and Without Thyroid Disorders

Thyroid Disorder Present

If thyroid gland has nodule or nodules

Thyroid Disorder Present

If thyroid gland is abnormally enlarged

Thyroid Disorder Present

(+) regional or distant mass considered metastatic from

occult thyroid cancer

Thyroid Gland

•Normally NOT palpable

•Palpable yet normal

•very thin patients

•physiologic enlargement

Thyroid Disorder NOT Present

• Gland is NOT palpable

•PR less than 90/min

•NO metastatic mass

Nomenclature of

Thyroid Disorders

When making a diagnosis,

know the name of the disease!

Colloid Adenomatous Goiter

• Diffuse colloid adenomatous goiter• Colloid cyst• Colloid adenomatous nodule• Multiple colloid adenomatous goiter

•Hyperthyroidism

•Hypothyroidism

Thyroid Cancer

• Papillary Cancer• Follicular Cancer• Medullary Cancer• Anaplastic Cancer

Thyroiditis

• Acute thyroiditis• Thyroid abscess• Chronic thyroiditis

Follicular AdenomaClinical Diagnosis

Follicular adenoma

vs follicular carcinoma

vs colloid adenomatous nodule

Clinical Classificationof

Goiters

Clinical Classification

• Diffuse toxic goiter• Diffuse nontoxic goiter• Nodular toxic goiter• Nodular nontoxic goiter

Diffuse Goiter

All lobes almost symmetrically enlarged

with NO nodule(s)

Diffuse GoiterNormal size thyroid gland

Clinical ClassificationNOT the same as

Clinical Diagnosis!

Diffuse Toxic GoiterHyperthyroidism

Diffuse Nontoxic GoiterDiffuse Colloid Goiter

Uninodular Toxic GoiterHyperthyroidism

Multinodular Toxic GoiterHyperthyroidism

Uninodular Nontoxic Goiter

Colloid cystColloid adenomatous nodule

Thyroid cancerChronic thyroiditis

Multinodular Nontoxic Goiter

Multiple Colloid adenomatous nodule

Thyroid cancerChronic thyroiditis

Nodular goitersNormal size thyroid gland

Diffuse goiterNormal size thyroid gland

Nodular goiter

Nodular Goiter

If one lobe is smoothly enlarged, the other lobe

is normal.

Physical Signs of

Thyroid Cancer

Suspect Malignancy

Nodular goitersSolid noduleFixed nodule

Suspect MalignancyLocal invasion

HoarsenessDysphagiaDyspnea

Skin infiltrationRegional spread

Distant metastasis

Clinical Diagnosisof

Thyroid Disorders

Diagnostic Process

• Proper methods of clinical evaluation• Identification of patients with or without

thyroid disorder• Nomenclature of thyroid disorders• Clinical classification of thyroid

disorders• Physical signs of thyroid cancer

Thyroid gland

NOT palpable

NO nodule

PR < 90/min

No cancer signs (elsewhere)

Thyroid gland

NOT palpable

NO nodule

PR < 90/min

No cancer signs (elsewhere)

Normal thyroid gland

Thyroid gland

Diffusely slightly enlarged

PR < 90/min

Adolescent/perinatal

Thyroid gland

Diffusely slightly enlarged

PR < 90/min

Adolescent/perinatal

Physiologic goiter

Diffuse goiter

PR > 90/min

No cancer signs

Diffuse goiter

PR > 90/min

No cancer signs

To rule out hyperthyroidism

Diffuse goiter

PR > 90/min

No cancer signs

Exophthalmos

Diffuse goiter

PR > 90/min

No cancer signs

Exophthalmos

Hyperthyroidism

Diffuse goiter

PR < 90/min

No cancer signs

Diffuse goiter

PR < 90/min

No cancer signs

Diffuse colloid adenomatous goiter

Solitary nodule, NOT hard

PR > 90/min

No cancer signs

Solitary nodule, NOT hard

PR > 90/min

No cancer signs

To rule out hyperthyroidism

Solitary nodule, cystic

PR < 90/min

No cancer signs

Solitary nodule, cystic

PR < 90/min

No cancer signs

Colloid cyst

Solitary nodule, hard solid

PR < 90/min

Solitary nodule, hard solid

PR < 90/min

Thyroid cancer

Solitary nodule, NOT hard solid

PR < 90/min

LYTIC skull mass

NO dysphagia

NO dyspnea

Solitary nodule, NOT hard solid

PR < 90/min

LYTIC skull mass

NO dysphagia

NO dyspnea

Follicular cancer with skull metastasis

Solitary nodule, NOT hard solid

PR < 90/min

Ipsilateral neck nodes

NO dysphagia

NO dyspnea

Solitary nodule, NOT hard solid

PR < 90/min

Ipsilateral neck nodes

NO dysphagia

NO dyspnea

Papillary thyroid cancer with neck node metastasis

Huge thyroid nodule, fixed

PR < 90/min

(+) dysphagia

(+) dyspnea

Huge thyroid nodule, fixed

PR < 90/min

(+) dysphagia

(+) dyspnea

Anaplastic Carcinoma

Multiple nodules

PR < 90/min

No cancer signs

Multiple nodules

PR < 90/min

No cancer signs

Multiple colloid adenomatous goiter

Multiple nodules

PR > 90/min

No cancer signs

Multiple nodules

PR > 90/min

No cancer signs

To rule out hyperthyroidism

Nodular gland

NO discrete mass

PR < 90/min

No cancer signs

Nodular gland

NO discrete mass

PR < 90/min

No cancer signs

Chronic thyroiditis

Tender fluctuant mass, thyroid

PR > 90/min

No cancer signs

Tender fluctuant mass, thyroid

PR > 90/min

No cancer signs

Thyroid abscess

Diffuse goiter

PR < 90/min

No cancer signs

Short obese stature

Slow body movements

Diffuse goiter

PR < 90/min

No cancer signs

Short obese stature

Slow body movements

Hypothyroidism

Diffuse goiter

PR < 90/min

No cancer signs

Slow body movements

Diffuse goiter

PR < 90/min

No cancer signs

Slow body movements

Hypothyroidism

Diffuse goiter

toxic goiter common

Nodular goiter

toxic goiter rare