Thyroid/Neck (Endocrinological)

 

Thank you for asking me to examine Harry who presented with neck discomfort.

 

The salient findings on examination were a diffuse/multi-nodular goiter without overt evidence of thyrotoxicosis or mass effect.

 

In further detail...

 

On general inspection, Harry appeared comfortable and non-agitated. He was dressed appropriately.

 

On inspection of the neck, there was an anterior enlargement, which moved upwards with swallowing but did not move on tongue protrusion, consistent with the thyroid gland. On palpation, there was a symmetrical diffuse goiter / bilateral multinodular enlargement (with no single dominant nodular) / nodular enlargement. It was non-tender.

• Symmetry, location, size, shape, consistency, tenderness, mobility, thrill

 

The lower edge was palpable, indicating no retrosternal extension / not palpable. If not palpable, there was / was not dullness to percussion over the manubrium.

 

There was / was not a thyroid bruit (Graves).

 

There was no submental, submandibular, superficial or posterior cervical, parotid, pre- and posterior auricular, occipital or supraclavicular lymphadenopathy. Carotid arteries were palpable, making malignant infiltration unlikely.

 

There was no evidence of mass effect with a negative Pemberton’s.

 

In terms of the thyroid status:

 

Hyperthyroid

On examination of the hands, there was/ was not a tremor. There was not thyroid acropachy. There was not palmar erythema, and the hands were not sweaty. The heart rate was ___ and regular/irregular.

 

There was not proximal myopathy in the arms, and the reflexes were normal/brisk.

 

In the face, there was/ was not exophthalmos (sclera below cornea when looking straight ahead). There was / was not lid lag. There was / was not ophthalmoplegia. Look from behind for proptosis.

 

In the legs, there was / was not pretibial myxedema. There was not proximal myopathy, or hyperreflexia.

 

On cardiovascular examination, there was no flow murmur, or signs of congestive heart failure.

 

Hypothyroid:

• On examination of the hands, there was/was no peripheral cyanosis, or dry, cold skin. There was no bradycardia.

• Reflexes were delayed.

• There was no proximal myopathy (rare)

• There was peri-orbital oedema, and loss of the outer one third of the eyebrows. The skin was dry, fine and smooth

• There was / was not slowness of speech (ask for name and address).

• Reflexes were delayed in the legs.

• There were no pleural or pericardial effusions (.... presumably rare).

 

In summary, Harry had evidence of a diffuse goiter without overt features of thyrotoxicosis or mass effect.

 

Differentials for neck mass include:

• Thyroglossal cyst - would move on tongue protrusion

• Branchial cysts

• Lymphadenopathy

• Vascular aneurysm

 

Differentials for aetiology of a Goitre include:

• Diffuse:

  • Graves - presumably treated

  • Primary hypothyroidism - Hashimoto

  • Thyroiditis - subacute

  • Iodine deficiency

  • Medications - e.g. lithium

  • Infiltrative - sarcoid, amyloid, chronic fibrosing (Riedel’s)

  • Idiopathic

• Non-toxic multinodular goiter

• Nodule:

  • Toxic adenoma

  • Cyst

  • Thyroid cancer