Suggested Books To Read During Your General Surgery Residency (Read More)
Bailey & Love's Surgery, 27th Edition Surgery Essence by Pritesh Singh (PGMEE) Sabiston's Textbook of Surgery
Farquharson's Textbook of Operative General Surgery, 10th Edition Surgery Sixer for NBE by Rajamahendran Surgery PreTest Self-Assessment and Review, Thirteenth Edition
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Thyroid Case Sheet Proforma

Thyroid Case



Name:
Age/Sex:
Occupation:
Residence:

Presenting Complaints

Swelling in front of Neck   Duration
  
History of Presenting Illness

  • H/O Swelling

  • Site
  • Duration
  • Onset
  • Progress of the swelling:
  • Associated

  • H/O Pain

  • Site
  • Duration
  • Onset
  • Character: Usually dull-aching
  • Radiation
  • Relieving factors
  • Aggravating factors

R/O Pressure Symptoms

  • H/O Difficulty in Swallowing: Solid or liquid  
  • H/O Difficulty in breathing  
  • H/O Hoarseness of Voice
  • H/O Drooping of the upper eyelid (ptosis), Absence of sweating of the face (anhidrosis)

R/O Hyperthyroidism
  
Primary Hyperthyroidism (Mainly CNS Symptoms)
  • H/O Tremors
  • H/O Irritability on slight provocation
  • H/O Insomnia
  • H/O Muscle Weakness

Primary Hyperthyroidism (Eye Symptoms)
  • H/O Bulging of eyes

  • Duration
  • Progress
  • History of redness of eye and watering
  • History of double vision
  • Loss of vision

Secondary Hyperthyroidism (Mainly Cardiovascular Symptoms)

  • H/O Palpitations
  • H/O Ectopic Beats
  • H/O Chest pain
  • H/O Breathlessness on exertion

Hyperthyroidism (Sympathetic Hyperstimulation)
  • H/O Increased sweating
  • H/O Heat intolerance  

Hyperthyroidism (Increased BMI)
  • H/O Increased Appetite
  • H/O Weight Loss

Hyperthyroidism (GI)
  • H/O Increased frequency of passing stools


R/O Hypothyroidism

  • H/O Weakness
  • H/O Lethargy
  • H/O Swelling of face
  • H/O Swelling of legs
  • H/O Intolerance to cold
  • H/O Constipation
  • H/O Hair fall (Madarosis- Loss of hair from lateral eyebrows - also seen in Leprosy)

  
R/O Malignancy

  • H/O Loss of Appetite
  • H/O Bone Pain
  • H/O Jaundice/ Abdominal Distension
  • H/O Chest Pain/ Breathlessness/ Cough with Hemoptysis

Past H/O

  • H/O Similar illness in past
  • H/O Irradiation to Neck in Childhood (Radiation Exposure- Papillary Carcinoma)
  • H/O DM/HTN/IHD/COPD/BA/Epilepsy

Personal H/O

  • H/O Smoking
    • Duration
    • No of Cigarettes/ Bidis per day
  • H/O Tobacco chewing
  • H/O Alcoholism
  • H/O Excessive consuming vegetables  of Brassica family, cabbages
  • H/O Iodized Salt intake ( Daily RDA:  150 mcg of iodine per person per day, 30-40 mcg iodine/gram of salt is added in iodized salt)

Menstrual H/O

LMP
Regular Cycle, Moderate Flow (3/30)
H/O Changes in Menstrual Cycle

Family H/O

H/O Similar illness
(MEN IIa IIb/ Dyshormogenetic Goitre/ Iodine def Goitre)

Treatment H/O
H/O Ongoing Medications (Antithyroid/Eltroxin/Propanolol)

Allergic H/O
H/S/O Allergy to specific medications  

Summarize the History

General Examination

Conscious/ Oriented/ Cooperative
Moderately built and nourished
ECOG (0-asymptomatic , 1-restricted strenuous activity, 2-ambulant capable of self care but no work activities, 3-Capable of only limited Self care, 4-bed ridden)
Pallor/ Cyanosis/Clubbing/ Pedal Edema/ Generalized Lymphadenopathy
Facies- Thyrotoxic Facies/ Myxedema Facies
Tremors of hands and tongue
Sweating of Palms

B.P-120/80
PR-88/ Min (Rate, Rhythm, Volume, Character (collapsing or not), Delay- Radioradial, Radiofemoral)

Regional Examination

Inspection
  • Swelling
    • Size
    • Site
    • Extent
    • Shape
    • Margins
    • Surface
    • Lower border seen as such/on swallowing
  • Movement of swelling with deglutition
  • Movement of swelling on protruding tongue (To differentiate Thyroid nodule from Thyroid Cyst)
  • Scars/ Sinuses/ Dilated Veins/ Pulsations
  • Venous prominence over chest wall
  • Eye Signs
    • Bulging of eyes (exopthalmos)
    • Visible upper sclera with upper eyelid spasm (Dalrymple’s sign)
    • Lid Lag (Von Graefe’s Sign)
    • No wrinkling of forehead on looking up (Joffroy’s)
    • No convergence on accomodation (Mobius)
    • Infrequent blinking (Stellwag)
    • Chemosis
    • Eye movements test (Comment on palsy, paralysis of inferior oblique and superior rectus muscle)
  • Pemberton's sign: Ask the patient to raise both upper limbs above the head and keep it for 2–3 minutes. If retrosternal prolongation is there, patient will have congestion and puffiness in the face with respiratory distress. The Pemberton's sign is then positive  

Palpation

  • Swelling
    • Temperature over the swelling
    • Tenderness
    • Site, Size, Shape and Extent Confirmed on palpation
    • Surface
    • Margin
    • Consistency: Hard, firm, soft cystic, variegated
    • Any Fixity to Skin, Strap Muscles, SCM, Trachea
    • Mobility from side to side

  • Positions of trachea and larynx
    • Any shifting to either side by the swelling
  • Kocher's test: Test for tracheal compression: (Not done routinely)
    • The swelling is pressed slightly on either side of trachea. If trachea is already compressed, or if there is tracheomalacia, patient will have stridor
    • Kocher’s test negative (no stridor)
    • Kocher’s test positive (stridor on compression of both lobes)
  • Palpate the carotid pulsation (Berry’s Sign)
    • Carotid pulsation may be felt at normal site (at the anterior border of sternocleidomastoid at the level of the upper border of thyroid cartilage)
    • Carotid pulse is not palpable on the side of the swelling (Berry’s sign positive)
    • Carotid pulse is palpable but is displaced laterally
  • Examination of Cervical Lymph Nodes
    • Examination of all the cervical lymph node groups: If lymph nodes are palpable then describe, which groups of lymph nodes are palpable
    • Number, site, surface, margin, consistency and mobility


Percussion

  • Percussion over the manubrium sterni  


Auscultation
  • Any bruit audible (Heard over Upper pole, in thyrotoxicosis)

Systemic Examination

Spine and Cranium: No Bony Swellings/ Tenderness
Oral Cavity: Clinically Normal (No visible intraoral swellings, Lingual thyroid)
CVS: S1 S2 Heard, No Murmurs
RS: Bilateral Air Entry +, Normal Vesicular BS, No Added Sounds
CNS: No neurological deficits
P/A: Soft, Not tender, BS+

Summary of the case

  
Provisional Diagnosis


  • Anatomical: Multinodular Goitre / SNG/ Diffuse
  • Pathological: Benign/ Malignant
  • Physiological: Hyperthyroid/ Hypothyroid/ Euthyroid
  • No Complications (Cardiac, Exopthalmos)
  • No Comorbidities


Investigations



  • To confirm the diagnosis
  • To R/O and Characterize Retrosternal Extension (if not clear clinically)
  • For Staging
  • Routine Investigation before surgery
Management