Brief Summary
This video is a comprehensive clinical class on thyroid swelling, featuring a case presentation by Chandana, a fourth-year MBBS student. The session is mentored by Professor Ganta, a seasoned surgeon and principal. The discussion covers key aspects of history taking, physical examination, differential diagnosis, and management of thyroid swellings, with a focus on undergraduate-level understanding. Key points include differentiating between hyperthyroidism and thyrotoxicosis, understanding compressive symptoms, and avoiding common pitfalls in presentation and examination.
- Importance of detailed history taking in diagnosing thyroid conditions.
- Differentiating between hyperthyroidism and thyrotoxicosis.
- Proper examination techniques and interpretation of findings.
- Avoiding common mistakes in case presentation.
Introduction and Case Presentation
The video starts with an introduction to the clinical class on surgery, focusing on a case presentation of thyroid swelling. Chandana, a fourth-year MBBS student, presents the case. Professor Ganta, a highly experienced surgeon and principal, mentors the session. He appreciates Chandana's brilliance and offers his expertise to guide her through the case.
Patient History: Chief Complaints and Medical Background
Chandana presents the case of a 58-year-old female from Karala with a 33-year history of swelling in the front of her neck, first noticed during her first pregnancy. The swelling was insidious in onset and gradually increased in size. The patient reports no pain, fever, or symptoms suggestive of hypo- or hyperthyroidism. She has no difficulty breathing or swallowing, and no hoarseness of voice. She had a blood transfusion for anemia two years prior. There is no family history of similar complaints or cancers. She is postmenopausal and has had three normal vaginal deliveries.
Critique of Initial Presentation
Professor Ganta advises against using "XYZ" for patient names, suggesting a more direct approach like "58-year-old female patient." He emphasizes presenting information in sentence format rather than bullet points. He commends Chandana for specifying the swelling as being in front of the neck, which immediately suggests a thyroid issue.
Differential Diagnosis and Key Historical Points
Professor Ganta questions why a lymph node swelling is less likely in this case, highlighting that lymph node swellings are typically lateral. The 33-year history suggests a benign condition. He emphasizes that the chief complaint can lead to a preliminary diagnosis of a benign thyroid swelling. He also points out the importance of knowing when the last pregnancy was.
Relevance of Fever and Swelling Characteristics
Professor Ganta explains that a history of fever is not relevant for anterior neck swellings unless suspecting thyroiditis, but it is crucial for lateral neck swellings to rule out tuberculosis. He differentiates between sudden and rapid increases in swelling size, associating rapid increases with bleeding and sudden increases with malignancy.
Hyperthyroidism vs. Hypothyroidism
Professor Ganta emphasizes the importance of asking about symptoms of hyperthyroidism in cases of goiter, as it is more commonly associated with goiter than hypothyroidism. He explains that hypothyroidism is often linked to thyroiditis, leading to gland fibrosis rather than goiter. He highlights the importance of understanding the reasoning behind each symptom of hyperthyroidism. He also clarifies the difference between hyperthyroidism and thyrotoxicosis, with thyrotoxicosis being the clinical manifestation of increased thyroid hormones, not necessarily due to a thyroid cause.
Compressive Symptoms and Goitrogenic Drug History
Professor Ganta notes that if compressive symptoms are expected in a goiter case, tracheal compression is the most common. He mentions that stridor in goiter cases could indicate thyroiditis or anaplastic cancer. He lists goitrogenic drugs like amiodarone, sulfonureas, lithium, and certain anti-asthmatics, as well as iodine-containing cough syrups.
Anemia and Surgical History
The discussion shifts to the patient's history of blood transfusions for anemia. Professor Ganta stresses the importance of including the reason for anemia (hemorrhoids and surgery for it) in the history, as it shows effort in finding the cause. He also discusses instances where blood transfusions might be needed in relation to thyroid issues, primarily post-surgery due to bleeding.
Family History and Menstrual Cycles
Professor Ganta highlights the relevance of family history in thyroid diseases like medullary thyroid carcinoma. He explains the relationship between menstrual cycles and thyroid diseases, detailing the reasons for oligomenorrhea in hyperthyroidism and menorrhagia in hypothyroidism.
Summary and Physical Examination
Professor Ganta advises simplifying the summary to highlight the goiter of benign etiology in a euthyroid state. Chandana then describes the general physical examination, noting the patient's calm demeanor, normal pulse rate and blood pressure, and the presence of pallor.
Pulse and Blood Pressure in Thyroid Conditions
Professor Ganta discusses the significance of pulse characteristics in thyroid swellings, particularly in hyperthyroidism, where increased pulse pressure and systolic hypertension are expected. He emphasizes the importance of checking blood pressure and demonstrating the collapsing nature of the pulse.
Febrile Nature and Nail Conditions
Professor Ganta clarifies that a febrile state is uncommon in thyroid cases unless it's a thyroid storm. He discusses nail conditions related to thyroid disease, such as thyroid acropachy with "dirty nails" in Graves' disease. He also mentions pretibial myxedema in hyperthyroidism.
Local Examination and Inspection
Chandana describes the local examination, noting a single diffuse swelling with three nodules. Professor Ganta advises following a structured approach: size, extent, surface, number, and added factors like movement with deglutition. He cautions against prematurely committing to the nodules being in specific lobes during inspection.
Hyoid Bone and Palpation Techniques
Professor Ganta clarifies that the hyoid bone is not a relevant anatomical reference for describing thyroid swellings. He emphasizes the importance of mentioning the lower border's visibility after noting movement with deglutition. He corrects the statement about the swelling moving with tongue protrusion, stating it's unnecessary for such a large, long-standing swelling. He also explains the correct palpation technique, including flexing the neck to relax strap muscles.
Carotid Pulsations and Kocher's Test
Professor Ganta specifies that when discussing carotid pulsations in relation to the thyroid, it refers to the common carotid artery. He discourages performing Kocher's test at the bedside.
Percussion and Summary
Professor Ganta explains that percussion is unnecessary in this case but can be done to detect mediastinal masses from medullary thyroid carcinoma. He advises simplifying the summary to highlight the multinodular goiter in a euthyroid state.
Differential Diagnosis and Investigations
When asked about differential diagnoses, Professor Ganta emphasizes that in this particular case, there is no need for any differential diagnosis except multinodular goiter. For investigations, Professor Ganta recommends starting with TSH to assess physiological status, followed by USG to determine anatomy (uni- or multi-nodular, malignant features). He suggests framing investigations to confirm the diagnosis, assess disease extent, and evaluate fitness for surgery. He deems technician scans unnecessary in this case, reserving them for suspected toxic nodules.
Treatment and Complications
Professor Ganta discusses total thyroidectomy as a treatment option, citing potential for compressive symptoms, secondary thyrotoxicosis, or, rarely, malignancy (follicular thyroid carcinoma). He outlines common complications: intraoperative bleeding and injury to surrounding structures, immediate postoperative reactionary bleeding and parathyroid insufficiency, and late complications like permanent hypoparathyroidism. He specifies that hypoparathyroidism typically manifests 24-48 hours post-surgery.
Postoperative Management and Tracheomalacia
Professor Ganta explains that tracheomalacia, or softening of the tracheal rings, can cause immediate post-extubation stridor, requiring reintubation. He stresses that the operating surgeon should remain with the patient until extubation and stable breathing are confirmed.
Additional Insights and Presentation Tips
Professor Ganta shares additional slides to illustrate key points. He emphasizes that the mouth should be kept open, and only the tongue should move during the protrusion test. He clarifies that the term "butterfly shape" applies only to normal thyroids, not diseased ones. He also highlights the importance of describing the lower border's visibility after mentioning movement with deglutition.
Key Questions and Conclusion
Professor Ganta concludes by mentioning a frequently asked question: why the thyroid moves with tongue protrusion and deglutition. He emphasizes the importance of knowing the exact answers to these fundamental questions.
