Thyroid Case Sheet Proforma

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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

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Thyroid Case Sheet Proforma

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MRCS Part A: Essential Revision Notes: Book 1
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MRCS Practice Papers Part A: Paper 2 EMQs

Rush University Medical Center Review of Surgery

Bailey & Love Companion Guide Mcqs & Emqs In Surgery

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Basic Science for the MRCS: A revision guide for surgical trainees

Oxford Handbook of Clinical Surgery

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Mrcs Module 2016 Question With Explanations For Mrcs The Best Question Series

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BEST BOOKS FOR MRCS PART B

DrExam Part B MRCS OSCE Revision Guide: Book 1

DrExam Part B MRCS OSCE Revision Guide: Book 2

OSCEs for the MRCS Part B: A Bailey & Love Revision Guide

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Get Through MRCS: Anatomy 2E

Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Harold Ellis

Essential Radiological Anatomy for the MRCS

Surgical Critical Care: For the MRCS OSCE by Mazyar Kanani and Simon Lammy

Surgical Critical Care Vivas by Mazyar Kanani

Mcminn’s Color Atlas of Human Anatomy

Netter’s Atlas of Human Anatomy

 

BEST MCQ BOOKS FOR GENERAL SURGERY

Surgery Essence By Pritesh Singh

Surgery Sixer for NBE by Rajamahendran 4th ed (2019)

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Schwartz’s Principles of Surgery ABSITE and Board Review

Surgery PreTest Self-Assessment and Review, 13th ed

SURGERY COMPLETE – 2019

Surgery For PGMEE 13th Edition – 2019 by Amit Ashish

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Bailey & Love’s Short Practice of Surgery, 27th Edition

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Operative Techniques in Surgery by Michael W. Mulholland et al

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