clinical diagnosis of thyroid disorders - a self-instructional program - rojoson - 1992

7/27/2019 Clinical Diagnosis of Thyroid Disorders - A Self-instructional Program - ROJoson - 1992

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CLINICAL DIAGNOSIS OF THYROID DISORDERS

Reynaldo O. Joson, M.D.

1992

INTRODUCTION

Thyroid disorders are very common in the Philippines. They are so common that practically all physicianswill every now and then be confronted with a patient with a thyroid problem. For these reasons it isrecommended that all physicians !now at least how to arrive to a clinical dia"nosis of a thyroid disorder.

The phrase #clinical dia"nosis$ is %sed here to mean the %tili&ation of history and physical e'amination inarrivin" to a dia"nosis. (ltho%"h there are other dia"nostic proced%res which may be done to eval%atepatients with a possible thyroid problem this pro"ram will be limited to clinical dia"nosis. F%rthermore itwill be limited to eval%ation of patients witho%t a history of previo%s treatment to their thyroid "land.

This pro"ram is desi"ned to be a practical theoretical co%rse on how to "o abo%t eval%atin" patients witha possible thyroid disorder )%st based on history and physical e'amination. It disc%ssed the proper%tili&ation of the methods of clinical eval%ation* the identification of patients with and witho%t thyroiddisorders* the nomenclat%re of thyroid diseases* the clinical classification of "oiters* the physical si"ns ofthyroid mali"nancy* and lastly the clinical dia"nosis of patients with thyroid disorders.

OBJECTIVES

Upon completion of this pro"ram the %ser is e'pected to be able to+

,. Utili&e properly the two basic methods of clinical eval%ation in patients with a possible thyroidproblem.

-. Determine which patients have and do not have a thyroid disorder.. Cite the nomenclat%re of thyroid disorders./. 0'plain the clinical classification of "oiters.

1. 0n%merate the physical si"ns of thyroid mali"nancy.2. 3a!e a lo"ical clinical dia"nosis of patients with thyroid disorders.

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RECOMMENDED PREPARATIONS

4efore "oin" thro%"h this pro"ram the %ser sho%ld have a basic bac!"ro%nd !nowled"e of the anatomyphysiolo"y and patholo"y of the thyroid "lands. 5e also m%st !now the f%ndamental principles in thedia"nostic process. The %ser is also advised to st%dy the followin" "lossary before before "oin" thro%"hthe pro"ram+

,. Thyroid patient 6 any patient presentin" with a possible act%al or obvio%s thyroid problem.-. Thyroid disorder 7 thyroid disease or problem.. 8oiter 6 ori"inally %sed to mean a beni"n enlar"ement of the thyroid "land* may be %sed

loosely to mean any thyroid disorder.

I. 30T5OD9 OF C:INIC(: 0;(:U(TION OF T5her nec! while at the same time %tterin" any of the followin"%s%al sentences or phrases+

,. I thin! I have a "oiter.-. I was told I have a "oiter.. I have a l%mp here in the nec!./. I have this feelin" of obstr%ction in my nec!. I may have a "oiter.

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(fter completion of the nec! e'amination the physician co%nts the p%lse rate. D%rin" thistime that the physician is e'aminin" and tal!in" to the patient he sho%ld loo! for other si"nsthat may s%""est thyroid disorder. 9pecifically he sho%ld loo! for e'ophthalmos* hoarsenessof voice* and a distant mass that may be a metastatic thyroid cancer.

Th%s at the very least the physical e'amination of a thyroid patient sho%ld incl%de thefollowin"+

,. Inspection of the nec!-. Palpation of the paratracheal area. Palpation of the lateral nec!/. P%lse rate1. :oo!in" for si"ns that may s%""est thyroid disorder s%ch as e'ophthalmos

hoarseness of voice and a distant mass that may be metastatic cancer.

C. IN7D0PT5 INT0R;I0A

Once a thyroid disorder is detected or s%spected thro%"h physical e'amination an in7depthinterviewin" or history ta!in" may now be %nderta!en In patients who have no previo%streatment the followin" aresome pertinent =%estions that may be as!ed+

,. Ahen was the thyroid disorder first notedB Not when did it startB-. If there is hoarseness of voice when did it occ%rB. If there is a re"ional or distant mass noticeable by the patient when was it first

discoveredB/. Is there any accompanyin" painB

The physician sho%ld avoid as!in" irrelevant =%estions or =%estions that see! answers thatare considered not reliable cl%es for thyroid disorder s%ch as e'cessive sweatin" easyfati"abiliaty and e'cessive appetite.

(ltho%"h this is not part of this pro"ram in patients with a history of previo%s treatmentin=%iries have to be made re"ardin" laboratory e'aminations medications operative records

and biopsy res%lts.

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REVIEW QUESTIONS I

Direction+ 9%pply the appropriate answers.

(. Name the two methods %tili&ed in the clinical eval%ation of thyroid patients.

,.-.

4. 0n%merate in a lo"ical se=%ence the minim%m physical e'amination that a physician m%st do to beable to arrive to a clinical dia"nosis in a thyroid patients

./.1.2.

E.

C. Name at least five characteristics of a thyroid nod%le that m%st be decribed d%rin" physicale'amination.

.G.,H.,,.,-.

Direction+ Indicate which of the followin" statements are tr%e T and which are false F by circlin" theappropriate letter.

T F ,. In thyroid patients physical e'amination plays a more important role thanhistory in the clinical dia"nosis.

T F ,/. The best position that the physician m%st ass%me when palpatin" a thyroidpatient@s nec! is in front of the patient.

T F ,1. (s!in" the patient to swallow is part of the physician@s techni=%e in palpatin" thethyroid patient@s nec!.

T F ,2. ( history of e'cessive sweatin" is an important information that m%st be loo!edfor d%rin" history ta!in" of a thyroid patient.

T F ,E. In7depth history ta!in" sho%ld be done before physical e'amination in a thyroidpatient.

Please check your answers on page 14.

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II. ID0NTIFIC(TION OF P(TI0NT9 AIT5 ( T5


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III. NO30NC:(TUR0 OF T5


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REVIEW QUESTIONS III

DIR0CTION+ 9%pply the appropriate answers.

(. 0n%merate the five ma)or types of thyroid disorders.,.-../.1.

4. 0n%merate the fo%r types of thyroid cancer.2.E..G.

C. 0n%merate the fo%r clinical forms of colloid adenomato%s "oiter.,H.,,.

,-.,.

D. 0n%merate the three clinical forms of thyroiditis.,/.,1.,2.


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I;. C:INIC(: C:(99IFIC(TION OF 8OIT0R9

There is a clinical classification of "oiters which is very helpf%l in arrivin" to a clinical dia"nosis.The classification consists of combinin" the physiolo"ic and anatomic abnormalitis of the thyroid"land. The clinical classification is as follows+

,. Diff%se to'ic "oiter-. Diff%se nonto'ic hoiter. Nod%lar to'ic "oiter/. Nod%lar nonto'ic "oiter

The nod%lar "oiters can f%rther be s%bdivided into the followin"+., Uninod%lar to'ic "oiter.- 3%ltinod%lar to'ic "oiter/., Uninod%lar nonto'ic "oiter/.- 3%ltinod%lar nonto'ic "oiter

( diff%se "oiter is said to be present if all the lobes of the thyroid "land are almost symmetricallyenlar"ed and there are no discrete nod%les. If a lobe of the thyroid "land is smoothly enlar"eddiff%sely witho%t discrete nod%le on palpation the clinical classification is not a diff%se "oiter b%ta nod%lar "oiter. The first reason for a nod%lar classification is that there is only a %nilobar

enlar"ement. The second reason is that s%ch a %nilobar enlar"ement %s%ally contains a nod%lewithin it.

( nod%lar "oiter is one that contains nod%le either sin"le or m%ltiple.

( to'ic "oiter is present if there are si"ns of hyperthyroidism. ( nonto'ic "oiter is present if thereare no si"ns of hyperthyroidism. The patient is %s%ally e%thyroid* rarely is hypothyroidism present.

( practical r%le of th%mb to follow is that if the p%lse rate is less than GH>min%te then the "oiterthat is palpably present is nonto'ic. If the p%lse rate is e=%al to or "reater than GH>min%te ahyperthyroidism has to be r%led o%t in the presence of a "oiter %sin" other data in the physicale'amination. It m%st be borne in mind that tachycardia may be present even in nonto'ic "oiter.

0ach of the cate"ories in the clinical classification of "oiter can be represented by severalcommon and %ncommon thyroid diseases. If a patient is classified %nder a specific cate"ory thenthe differential dia"nosis will incl%de all the diseases listed %nder it. If there are common and%ncommon diseases %nder the said cate"ory then the more common disease is the more li!elydia"nosis %nless there are ob)ective data to point to the less common diasese.

4elow is a tab%lation of the different thyroid diseases %nder each clinical classification of "oitersto"ether with their relative prevalence+

DIFFU90 TO?IC 8OIT0R

5yperthyroidism common

DIFFU90 NONTO?IC 8OIT0R

Diff%se colloid "oiter commonChronic thyroiditis not common

UNINODU:(R TO?IC 8OIT0R not common

5yperthyroidism

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3U:TINODU:(R TO?IC 8OIT0R not common

5yperthyroidism

UNINODU:(R NONTO?IC 8OIT0R

Colloid cyst very commonColloid adenomato%s nod%le very commonThyroid cancer commonChronic thyroiditis not common

3UT:INODU:(R NONTO?IC 8OIT0R

3%ltiple colloid adenomato%s "oiter very commonThyroid cancer commonChronic thyroiditis not common

REVIEW QUESTIONS IV

DIR0CTION+ 9%pply the appropriate answers

0n%merate the si' cate"ories in the clinical classification of "oiters that combine physiolo"ic andstr%ct%ral abnormalities of the thyroid "land and "ive one common representative thyroid disease %ndereach cate"ory+

,.-../.1.2.


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( clinical dia"nosis of patients with thyroid disorders is an ed%cated "%ess that is derived basedprimarily on the ob)ective data obtained from the physical e'amination and secondarily on theprevalence of the diseases and statistical probabilities.

The dia"nostic process is "reatly facilitated if the physician has obtained the followin" !nowled"eand s!ills+

,. Proper methods of clinical eval%ation.-. Identification of patients with and witho%t a thyroid disorder.. The f%nctional nomenclat%re of thyroid disorders./. The clinical classification of "oiters.1. The physical si"ns of thyroid mali"nancy.

4elow is a tab%lation showin" essential data obtained from a patient and the correspondin"clinical dia"nosis that sho%ld be made.

D(T( C:INIC(: DI(8NO9I9

Case , Diff%se "oiter* PR J GH>min%teNo si"ns of mali"nancy

To r%le o%t hyperthyroidism beforeacceptin" diff%se colloid "oiter

Case - Diff%se "oiter* PR J GH>min%teNo si"ns of mali"nancy0'ophthalmos

5yperthyroidism with e'ophthalmos

Case Diff%se "oiter* PR K GH>min%teNo si"ns of mali"nancy

Diff%se colloid "oiter

Case / 9olitary thyroid nod%le not hard solidPR J GH>min%teNo si"ns of mali"nancy

To r%le o%t hyperthyroidism beforeacceptin" colloid adenomato%s "oiter

Case 1 9olitary thyroid nod%le cystic

PR J GH>min%teNo si"ns of mali"nancy

Colloid cyst> colloid adenomato%s nod%le

Case 2 9olitary thyroid nod%le hard solidPR K GH>min%te

Thyroid cancer most probably papillary byprevalence

Case E 9olitary thyroid nod%le hard fi'ed solidPR K GH>min%te

Thyroid cancer most probably papillary byprevalence

Case 9olitary thyroid nod%le not hard solidPR K GH>min%te9!%ll mass lytic* no dyspha"ia no dyspnea

Follic%lar carcinoma with s!%ll metastasis

Case G 9olitary thyroid nod%le not hard solidPR K GH>min%teIpsilateral nec! nodes

Papillary carcinoma with nec! nodemetastasis

Case ,H 5%"e thyroid nod%le fi'ed to the prevertebralfascia with dyspha"ia and dyspneaPR J GH>min%te

(naplastic carcinoma

Case ,, 3%ltiple thyroid nod%les 3%ltiple colloid adenomato%s "oiter

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PR K GH>min%teNo si"ns of mali"nancy

Case ,- 3%ltiple thyroid nod%lesPR J GH>min%teNo si"ns of mali"nancy

To r%le o%t hyperthyroidism beforeacceptin" m%ltiple colloid adenomato%s"oiter

Case , Nod%lar thyroid "landNo discrete massPR K GH>min%teNo si"ns of mali"nancy

Chronic thyroiditis

Case ,/ Tender fl%ct%ant mass on the thyroid "landPR J GH>min%teNo si"ns of mali"nancy

Thyroid abscess

Case ,1 Diff%se "oiter PR K GH>min%te9hort obese stat%re with %n%s%ally slow bodymovements

To r%le o%t hypothyroidism

In the above tab%lation there are sit%ations in which clinical dia"nosis can be made with easeand certainty. There are also sit%ations in which the clinical dia"nosis is made with reservations.The latter sit%ations are enco%ntered primarily in those with a p%lse rate of GH>min%te or "reaterand in which there are no reliable ob)ective data available to r%le o%t hyperthyroidism. These areseen in cases , / and ,-. (nother factor that contrib%tes to the e=%ivocal clinical dia"nosis is therarity of the disease as seen in cases / ,- and ,1.

In case 1 the clinical dia"nosis is colloid cyst> colloid adenomato%s nod%le. Oftentimes it is hardto differentiate the two clinical "ro%nd especially if the nod%le is small. 4oth can have the sameconsistency that is cystic beca%se both have fl%id content. It is only in a lar"e colloid cyst abo%t cm or "reater that a confident dia"nosis can be made. In s%ch a lar"e si&e cyst there is moreelbow room to displace the fl%id inside so as to "ive the dia"nosis away.

There are certain thyroid diseases which cannot be made on clinical "ro%nds. One reason isbeca%se of rarity that it sho%ld not be the primary dia"nosis. (n e'ample is med%llary thyroidcarcinoma. (nother reason is that there are no clinical data stron" eno%"h to s%pport it. (ne'ample is follic%lar adenoma. ( solitary thyroid nod%le can be a follic%lar adenoma. 5oweversince the characteristics of the nod%le of follic%lar adenoma are hard to differentiate from those ofa colloid adenomato%s nod%le and since the latter thyroid disease is more common the latterdia"nosis is %s%ally made.

( m%ltinod%lar nonto'ic "oiter witho%t physical si"ns of mali"nancy can be a follic%lar carcinoma.5owever a m%ltiple colloid adenomato%s "oiter is %s%ally "iven as a clinical dia"nosis beca%se itis the most common ca%se. It is only when there is a distant mass s%spected of metastasis that adia"nosis of follic%lar carcinoma is made as is seen in Case .

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REVIEW QUESTIONS VI

DIR0CTION+ 8iven the clinical data in Col%mn ( ma!e a clinical dia"nosis and write it downon the space %nder Col%mn 4.

Col%mn ( Col%mn 4

,. Diff%se "oiter PR L ,-H>min%tee'ophthalmos no si"ns of mali"nancy

,. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

-. 9olitary thyroid nod%le hard and fi'ed* PR LH>min%te* No distant metastasis

-. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

. 9olitary thyroid nod%le cystic* PRLH>min%te*No si"ns of mali"nancy

. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

/. 9olitary thyroid nod%le cystic* PRLH>min%te*Collapse of vertebral bodies* No dyspnea

/. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

1. 9olitary thyroid nod%le not hard solid*PRLH>min%te* Ipsilateral nec! nodes

1. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

2. 5%"e thyroid mass fi'ed* dyspha"iadyspnea* PR L ,HH>min%te

2. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

E. 3%ltiple thyroid nod%les* PRLH>min%te* Nosi"ns of mali"nancy

E. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

. Nod%lar thyroid "land* No discreet mass* PR LEH>min%te

. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

G. Diff%se "oiter* PR L 2H>min%te* No si"ns of

mali"nancy

G. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

,H. Diff%se "oiter* PR L ,-H>min%te* No si"ns ofmali"nancy

,H. MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

Please chec! yo%r answers on pa"e ,1

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ANSWERS TO REVIEW QUESTIONS

I. Review =%estion I,. 5istory-. Physical e'amination. Inspection of the nec!/. Palpation of the paratracheal area1. Palpation of the lateral nec!2. P%lse rateE. :oo!in" for other si"ns that will s%""est thyroid disorders. 9i&eG. Consistency,H. Fi'ation or mobility,,. Tenderness,-. location,. T,/. F,1. T,2. F,E. F

II. Review =%estions II,. The thyroid "land is not palpable-. There is no palpable thyroid nod%le. The p%lse rate is less than GH>min%te/. There is no re"ional or distant mass to s%""est metastatic cancer from an occ%lt primary thyroid

cancer.1. ;ery thin patients2. Physiolo"ic "oiter d%rin" adolescenceE. Physiolo"ic "oiter d%rin" pre"nancy. If the patient manifest si"ns of hyperthyroidismG. If the patient manifest si"ns of hypothyroidism,H. If the thyroid "land is abnormally enlar"ed

,,. If the thyroid "land contains a nod%le or m%ltiple nod%les,-. If the patient has re"ional or distant mass considered to be metastatic cancer from an occ%lt

primary thyroid cancer.

III. Review =%estions III,. Colloid adenomato%s "oiter-. 5yperthyroidism. 5ypothyroidism/. Thyroid cancer1. Thyroiditis2. Papillary carcinomaE. Follic%lar carcinoma. (naplastic carcinoma

G. 3ed%llary carcinoma,H. Diff%se colloid "oiter,,. Colloid cyst,-. Colloid adenomato%s "oiter,. 3%ltiple colloid adenomato%s "oiter,/. (c%te thyroiditis,1. Thyroid abscess,2. Chronic thyroiditis

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I. Review =%estion I;,E. Diff%se to'ic "oiter 7 hyperthyroidism,. Diff%se nonto'ic "oiter 7 diff%se colloid "oiter ,G. Uninod%lar to'ic "oiter 7 hyperthyroidism-H. 3%ltinod%lar to'ic "oiter 7 hyperthyroidism-,. Uninod%lar nonto'ic "oiter 7 colloid adenomato%s "oiter

7 colloid cyst7 thyroid cancer7 any of these

--. 3%ltinod%lar nonto'ic "oiter 7 m%ltiple colloid adenomato%s "oiter7 Thyroid cancer7 Chronic thyroiditis7 any of the above

II. Review =%estions ;-. 5ard solid thyroid nod%le. Fi'ed thyroid nod%le/. 5oarseness of voice1. Cervical lymph nodes considered to be metastatic

2. Distant mass that is considered to be metastaticE. F. F

I. Review =%estions ;I-. hyperthyroidism-/. thyroid cancer most probably papillary cancer-1. Colloid cyst> colloid adenomato%s nod%le-2. Follic%lar carcinoma-E. Papillary carcinoma-. (naplastic carcinoma-G. 3%ltiple colloid adenomato%s "oiterH. Chronic thyroiditis

,. Diff%se colloid "oiter-. 5yperthyroidism

R0F0R0NC09

,. De8own 0: De8own R:+ 4edside Dia"nostic 0'amination. New


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POST-TEST

I. DIR0CTION+ Indicate which of the followin" statement are tr%e T and which are false F bycirclin" the appropriate letter.

T F ,. In the clinical eval%ation of thyroid patients physical e'amination plays a more importantrole than history.

T F -. ( mass in the paratracheal area that moves with de"l%tition is a thyroid disorder %ntilproven otherwise.

T F . ( patient with a diff%se "oiter with a history of e'cessive sweatin" and easy fati"abilityand a p%lse rate of less than GH>min%te sho%ld be s%spected to have hyperthyroidism.

T F /. ( thyroid disorder is considered not to be present if e'amination of the nec! and the restof the body shows no abnormality and the p%lse rate is H>min%te.

T F 1. ( clinically palpable thyroid "land can be normal.

T F 2. It is only in thyroid nod%les that a mali"nancy is incl%ded in the differential dia"nosis.

T F E. ( cystic thyroid nod%le is beni"n %ntil proven otherwise.

T F . ( hard solid thyroid nod%le is mali"nant %ntil proven otherwise.

T F G. 3ed%llary thyroid carcinoma is very rare in the Philippines.

T F ,H. Nod%lar to'ic "oiter are rare compared to diff%se to'ic "oiter.

T F ,,. ( nonto'ic "oiter is synonymo%s with e%thyroid "oiter.

T F ,-. Chronic thyroiditis is not common in the Philippines.

T F ,. 5yperthyroiidsm can present as a diff%se as well as a nod%lar "oiter.

T F ,/. Follic%lar (denoma and colloid adenomato%s nod%le are synonymo%s.

T F ,1. ( p%lse rate of ,HH>min%te or "reater is patho"nomonic of to'ic "oiter.

II. DIR0CTION+ Choose the best answer by circlin" the appropriate letter.

,2. ( ,/ year old female presented with a solitary soft thyroid nod%le and m%ltiple ipsilateral nec! nodes.The p%lse rate was ,HH>min%te. Ahat is yo%r dia"nosisBa. Follic%lar carcinomab. Papillary carcinomac. Colloid adenomato%s nod%le and t%berc%lo%s lymphadenopathyd. Uninod%lar to'ic "oiter

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,E. ( 1H year old female presented with a solitary thyroid nod%le / cm in si&e and cystic. There were nonec! nodes nor masses in other parts of the body. The p%lse rate was H>min%te. Ahat is yo%rdia"nosisBa. Papillary carcinomab. Follic%lar carcinomac. Colloid cystd. Colloid adenomato%s "oitere. Nod%lar to'ic "oiter

,. ( /H year old female presented with m%ltiple nod%les on the thyroid "land. The nod%les were ofdifferent consistencies. 9ome were firm. 9ome were cystic. The p%lse rate was H>min%te. Therewere no nec! nodes. There was no mass in other parts of the body. Ahat is yo%r dia"nosisBa. Follic%lar carcinomab. Papillary carcinomac. 3%ltiple colloid adenomato%s "oiterd. 3%ltinod%lar nonto'ic "oitere. Chronic thyroiditis

,G. ( -- year old female presents with a diff%se "oiter and a p%lse rate of ,-H>min%te. There was noe'ophthalmos. There was a palpable lymph node in the ri"ht s%bmandib%lar area. Ahat is yo%r

dia"nosisBa. 5yperthyroidismb. 8rave@s diseasec. Diff%se to'ic "oiterd. Diff%se nonto'ic "oitere. Papillary carcinoma

-H. ( /H year old female presented with a - cm hard thyroid nod%le to"ether with a parieto7occipital masswhich on '7ray shows lytic chan"es on the s!%ll. The p%lse rate was ,HH>min%te. Ahat is yo%rdia"nosisBa. (naplastic carcinomab. Follic%lar carcinomac. 3ed%llary carcinoma

d. Papillary carcinomae. Nod%lar to'ic "oiter

-,. ( ,G year old female presented with a h%"e movable diff%sely enlar"ed thyroid "land. The p%lse ratewas H>min%te. There were no nec! nodes nor masses in other parts of the body.a. Diff%se non7to'ic "oiterb. Diff%se colloid "oiterc. Iodine7deficiency "oiterd. Physiolo"ic "oiter

--. ( /H year old female presented with a hard fi'ed nod%le on the ri"ht lobe of her thyroid "land. Thep%lse rate is ,HH>min%te. There were no nec! nodes nor other masses in other parts of the body.Ahat is yo%r dia"nosisB

a. Papillary carcinomab. Follic%lar carcinomac. (naplastic carcinomad. Nod%lar to'ic "oiter

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-. ( 2H year old female presented with an 7cm thyroid mass which was firm non7tender and fi'ed.The mass moves minimally with de"l%tition. The p%lse rate was ,HH>min. The patient was dyspneic.Ahat is yo%r dia"nosisBa. Papillary carcinomab. Follic%lar carcinomac. (naplastic carcinomad. 3ed%llary carcinomae. Nod%lar to'ic "oiter

-/. ( ,/ year old female presented with a solitary nod%le on the left lobe of her thyroid "land. The nod%lewas - cm in si&e soft movable and not tender. There were no nec! nodes nor masses in other partsof the body. The p%lse rate was H>min. Ahat is yo%r dia"nosisBa. Follic%lar adenomab. Colloid adenomato%sc. Papillary thyroid carcinomad. Nod%lar non7to'ic "oiter

-1. ( 1H year old female presented with m%ltiple thyroid nod%le of different consistencies. The p%lse ratewas ,HHH>min. There was a clavic%lar t%mor which on '7ray shows lytic chan"es. Ahat is yo%rdia"nosisB

a. 3%ltiple colloid adenomato%s "oiter with bone cancerb. (naplastic carcinomac. Papillary carcinomad. Follic%lar carcinomae. 3ed%llary carcinoma

Please chec! yo%r answers on pa"e ,G.

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ANSWERS TO POST TEST

I. ,. T II. ,2. 4-. T ,E. C. F ,. C/. T ,G. (1. T -H. 42. T -,. 4E. T --. (. T -. CG. T -/. 4,H. T -1. D,,. F,-. T,. T,/. F,1. F

R0CO330ND0D FO::OA7UP

(fter completin" this self7instr%ctional pro"ram the %ser is advised to apply what he learns from

this pro"ram in the clinics. 5e is enco%ra"ed to disc%ss this pro"ram with his peers and his teachers.

(fter a clinical dia"nosis thyroid f%nction tests needle eval%ation and other dia"nosticproced%res may have to be done. If the %ser is interested in the f%rther mana"ement of a thyroid patientafter clinical dia"nosis he can read on the different dia"nostic proced%re.

(4OUT T50 (UT5OR

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Dr. Reynaldo O. oson is presently an assistant professor at the Department of 9%r"ery of theUniversity of the Philippines colle"e of 3edicine. 5e is also presently the actin" chief of the Division of5ead and Nec! 4reast 0sopha"%s and 9oft Tiss%e 9%r"ery of the Department of 9%r"ery at thePhilippine 8eneral 5ospital. From ,G to ,GG, he was the Director of the U.P. Post"rad%ate Instit%te of3edicine. 5e is a diplomate of the Philippine 4oard of 9%r"ery.

In ,G2 he wrote a boo! entitled # Thyroid 9%r"ical Diseases # which is widely read by s%r"eonsin the Philippines. 5e has so far written ei"ht boo!s and man%als. 5e has twenty fo%r p%blished researcharticles as senior a%thor as of ,GG,.

5e obtained a master@s de"ree in hospital administration in ,GG, and he is the assistant medicaldirector of the 3anila Doctor@s 5ospital from ,G %p to the present.

clinical diagnosis of thyroid disorders - a self-instructional program - rojoson - 1992

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