Tiêu đề BREAST & ENDOCRINE ✅

TOPIC : BREAST AND ENDOCRINE LONG CASE 1. HISTORY TAKING THYROID AND ANTERIOR NECK LUMP 1. 4C a. Complain ❖ Anterior neck lump ❖ Ask for possible associated symptoms: ● Symptoms specific to Graves' disease: eye symptoms ❖ Explore risk factors for different thyroid conditions: ● Graves' disease: family history of Graves' disease or autoimmune disorders (type 1 DM, myasthenia gravis, Hashimoto's disease) ● Toxic MNG: dietary iodine deficiency ● Thyroid adenoma: family history of thyroid disorder Thyroid carcinoma: family history of thyroid cancer or MEN,personal history of thyroid disease, previous radiation to the neck ● Hashimoto thyroiditis: personal history of autoimmune diseases, also associated with non-Hodgkin lymphoma ● DeQuervain thyroiditis: personal history of TB b. Course ❖ Convince that the swelling is from thyroid ❖ Differentiate between benign and malignant thyroid swelling Symptoms suggestive of malignant swelling: progressively increasing in size, usually solitary, painless, usually euthyroid ❖ Onset (gradual or sudden), duration (rate of growth of neck mass) ❖ Size (Diffuse or one side predominant? Any sudden increase in size? ; Size of the neck lump: (stayed the same size, smaller or bigger? ● increases gradually: Thyroid cancer(progressively growing), Thyroid nodule, Hashimoto Thyroiditis ● Increases rapidly: Aggressive thyroid cancer and some thyroid cyst ❖ Red Flags – dysphonia, dysphagia, or dyspnoea (see below) ❖ About SYMPTOMATOLOGY - Most patients with thyroid nodules have few or no symptoms.
c. Cause ❖ History of autoimmune disease e.g. type I DM, SLE, RA, pernicious anaemia (associations with Graves and Hashimoto’s) ❖ History of cancer elsewhere – metastatic disease to the thyroid; lymphoma; papillary cancer is associated with familial polyposis syndromes ask about GI polyps/cancers ❖ History of thyroid disease – long-standing MNG can progress to lymphoma ❖ Occupational history – any exposure to ionizing radiation (papillary cancer risk ↑3x) ❖ Family history of thyroid cancer, history of radiation to neck or head area? – ~20% of medullary cancers are familial (MEN2, AD inheritance), ~ 5% of papillary cancers ❖ Smoking, alcohol consumption ❖ About previous treatment for any thyroid disease ● Medications e.g. propylthiouracil, carbimazole, propranolol – length, efficacy, side effects ● Radioactive iodine treatment – what was the result? Is the patient receiving replacement? ● Surgery – what kind of surgery, any complications? ● Follow-up – what investigations done? ❖ Painful lump or painless ● Painful lump: haemorrhage in the cystic nodule, de Quervain’s thyroiditis, infective lymphadenopathy ● Painless lump: most thyroid-related disease ● Progressive and painful enlargement consider anaplastic carcinoma or primary lymphoma ❖ Are there any other lumps? If the patient has noticed other similar lumps elsewhere on their body (for example, groin or axilla) then it is likely that the lump represents either a systemic disease (e.g. HIV, tuberculosis) or disseminated malignancy (e.g. lymphoma). d. Complications ❖ SVC obstruction: fullness sensation in the head, shortness of breath, oedema of upper extremities and face, prominent dilated veins on chest, face and upper extremities ❖ Complications of thyrotoxicosis: Atrial fibrillation ❖ Cardiomyopathy, heart failure ❖ Metastatic symptoms: persistent spinal tenderness, prolonged coughing, haemoptysis
2. Systemic Review a. Exclude complications- refer table above b. Exclude other diagnosis ❖ Differential diagnosis for thyroid swelling: 1. Multinodular goitre 2. Graves’ disease 3. Thyroid adenoma 4. Thyroid carcinoma 5. Hashimoto thyroiditis 6. De Quervain thyroiditis 7. Cyst (simple, colloid, or haemorrhagic) 8. Lymphadenopathy 9. Thyroglossal cyst 3. Past Medical History a. Chronic Disease i. When was diagnosed ii. How was diagnosed ( first symptoms/ incidental) iii. Investigation done to diagnose- the result iv. Treatment for the disease/ medication/any surgery done v. Compliance to medication vi. Current control or status vii. Complication of disease and treatment (if present) 4. Past Surgical History a. Past thyroid surgery, any active Complaint b. Current control or status c. Complications of disease and surgery d. Compliance with Dr recommendations 5. Social History i. Access to health care ii. Knowledge of the disease iii. How the disease affects the patient's lifestyle iv. Bantuan kewangan dari mana mana jabatan
PHYSICAL EXAMINATION THYROID AIM: thyroid ± lymphadenopathy ± features of malignancy ± compressive symptoms ± current thyroid status (hyper / hypo / euthyroid) A. THYROID GLAND 1. Greet Patient and ask for permission to examine (any voice hoarseness – RLN invaded) 2. Position patient and expose adequately – entire neck, sternum and clavicles INSPECTION: 3. Inspection from the front ● Any swelling? ● Any scars? (any transverse incision in a skin crease, 2FB above suprasternal notch) ● Any skin changes over the mass? ● Any stigmata of hyperthyroidism (i.e. agitation) or hypothyroidism (i.e. bradykinesia) ● Check for a plethora of face, distended neck veins – may be due to compressive nature of mass (but rarely seen). Consider Differential Diagnosis for thyroid lump: ● Check if mass moves on swallowing by asking patient to take a sip of water – “Please take a sip of water and hold it in your mouth, do not swallow until I tell you to.” ● Check if mass moves on protruding the tongue – “Please open your jaw slightly. Now, without moving your jaw, please stick your tongue out and back in again.” ● Check if mass moves on swallowing or tongue protrusion again with hands palpating thyroid * A thyroid swelling moves only on swallowing; a thyroglossal cyst will move on both swallowing and protrusion of the tongue PALPATION: Palpate thyroid from BEHIND – one side at a time with the opposite hand stabilizing the gland. Gently tilt the head forward to relax anterior neck muscles, rest fingers on lateral lobe of thyroid (Ask for pain before palpating!) 1. Characteristics of lump and surrounding skin: