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8/18/2019 Grand Round - Neck Lumps
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Neck LumpsNODULES AND NEOPLASMS BY NITY
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Presenting Complaint
! "ear ol# $emale re%erre# to En#ocrinolog" clinic %or e&aluation ono#ule(
Patient reports t'is mi#line neck lump )as %oun# inci#entall" )'ile getting rea#" %or )ork one morning(
S'e )ent to 'er *P+ )'o re%erre# 'er to t'e En#ocrinolog" Clinic at
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Di-erentials.
T'"roi#Non/t'"roi#
P'"siological goitre Lipoma
Multino#ular goitreDermoi# c"st
*ra&es0 #iseaseEpi#ermal c"st
,as'imoto0s t'"roi#itis
A1scess
T'"roglossal c"stL"mp'oma
T'"roi# c"st
Carcinoma
Su1acute t'"roi#itis 2#e 3uer&ain0s+ 4ie#el0s5
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,istor" Intro#uction 6 Consent
C'eck Name an# Age
Occupation
Presenting Complaint
,istor" o% Presenting Complaint
C'eck ICE
Constitutional S"mptoms 7 Une8 9eig't loss+ Une8 C'ange in appetite+ $e&er+ Energ" le&els
Past Me#ical ,istor" 7 Dia1etes+ ,ig' BP+ C'olesterol+ Stroke+ ,eart Attack
Drug ,istor" 7 Allergies+ 4egular Drugs+ OTC Me#s.
$amil" ,istor"
Social ,istor"
ICE
Summarise
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Lump Speci:c ,istor"
;( ,o) long 'as t'e lump 1een t'ere.( ,as t'e lump got 1igger or smaller.
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Important Points / Patient,istor"
;( An" autoimmune #isor#ers.( >no)n risk %actors %or t'"roi# malignanc"
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Important Points / Patient,istor"
Patient reports 'er &oice seems to 'a&e 1ecome slig'tl" more 'usS'e recalls onl" occasional #iscom%ort )it' sensation t'at somet'inpus'ing in( Denies s'ortness o% 1reat'(
Denies %amil" 'istor" o% t'"roi# cancer
Denies personal 'istor" o% ra#iation t'erap" or t'"roi# or an" ot'ercancer
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E8amination
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Lump Speci:c E8amination
;( Location Super:cial@Deep( 4elations'ip to ot'er structures
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E8amination 9'at components o% t'e p'"sical e8am are critical %or t'is patient.
?$ull ,ea# an# neck e8am to look %or an" lumps or 1umps
?Palpate %or l"mp'a#enopat'"
?Palpate t'"roi# %or no#ularit"+ :rmness or 'ar# masses
?Pem1erton0s sign
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E8amination On p'"sical e8am+ "ou palpate a grossl" enlarge# t'"roi# glan# )it#ominant no#ule on t'e rig't t'"roi# lo1e
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3uestion A%ter t'oroug' 'istor" an# p'"sical+ )'at )oul# "ou or#er :rst %or tpatient.
?A( T'"roi# %unction tests 2TS,+ T=5
?B( CT neck
?C( M4I neck
?D( 4a#ioacti&e Io#ine uptake scan
?E( All o% t'e a1o&e
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3uestion A%ter t'oroug' 'istor" an# p'"sical+ )'at )oul# "ou or#er :rst %or tpatient.
?A( T'"roi# %unction tests 2TS,+ T=5
?B( CT neck
?C( M4I neck
?D( 4a#ioacti&e Io#ine uptake scan
?E( All o% t'e a1o&e
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9'at Ne8t.
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3uestion Patient is sent %or la1s as )ell as $NA( Patient returns to clinic t'e %)eek )it' $NA report rea#ing cannot rule out %ollicular neoplasmsurger" in#icate#.
Yes
No
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3uestion Patient is sent %or la1s as )ell as $NA( Patient returns to clinic t'e %)eek )it' $NA report rea#ing %ollicular cells+ cannot rule out %ollicneoplasm( Is surger" in#icate# %or "our patient at t'is time.
? Yes
?No
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In#ications %or T'"roi#ectom/,"pert'"roi#ism 2*ra&e0s5 not responsi&e to me#ical t'erap"
/Malignanc" 2con:rme# or 'ig' suspicion 1ase# on 'istor" an#@or $N
/*oitre )it' compressi&e s"mptoms
/Large t'"roi# no#ule 2Fcm5 t'at is una1le to 1e a#eGuatel" samp2sampling error #ue to large area o% no#ule an# risk o% com1inationan# malignant cells5
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T'"roi# No#ules Benign
? Benign t'"roi# c"sts 2#egenerate# no#ules5
? Colloi# no#ules
? Multino#ular goiter
Malignant? Papillar" carcinoma
? $ollicular carcinoma
? ,urt'le cell tumor
? Me#ullar" T'"roi# Carcinoma
? Anaplastic Carcinoma
? L"mp'oma o% t'"roi#
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Imaging / Ultrasoun#
/ CT Neck %or surgical planning
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Treatment Me#ical Management?In&ol&e en#ocrinolog" earl" to assist in management? T'"roi# 'ormone replacement %or '"pot'"roi#ism
? T'"roi# suppression %or '"pert'"roi#ism
?I/;
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Treatment / Post/surgical t'erap"?I/;
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Algorit'm@O&er&ie)
FNA
Benign
Malignant or
suspicious
indeterminate
surgeryTissue
pathology
Thyroid nodule/mass
$ollo)clinicall"
R e p e a t F N A
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/Intraoperati&e/ Blee#ing
/ Damage to arteries@&eins o% neck
/Postoperati&e presentation/ InHur" to recurrent lar"ngeal ner&e
/ Unilateral7 'oarseness
/ Bilateral7 respirator" #istress
/ Blee#ing
/ E8pan#ing 'ematoma causes compression+ s'ortness o% 1reat'/ ,"pocalcemia
/ 4emo&al or inHur" to parat'"roi# glan#s or t'eir 1loo# suppl"
/ Scar
Complications o% t'"roi#ecto
If patient develops expanding
neck hematoma
postoperatively treatment
involves immediate opening of
sutures to evacuate clot and
return to !R to explore and
stop "leed
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Take 'ome Points / Al)a"s o1tain t'"roi# %unction tests as part o% intial )opatient )it' t'"roi# pat'olog"
/ Per%orm %ull ,ea# Neck e8am
/ T'"roi# no#ules s'oul# un#ergo $NA %or c"topat'olog"