ROJoson PEP Talk: GOITER Management Part 2 - Fundamentals and Generalities Contents: Clinical Diagnosis of Goiters Paraclinical Diagnostic Procedures for Goiters

1. Empowerment
objective - for
laypeople to have an
understanding of
the FUNDAMENTALS
and GENERALITIES in
the MEDICAL
MANAGEMENT of
GOITER – Part 2.
Health
Disorder
Course–
Fundamentals
and
Generalities in
Medical
Management
of Goiter –
Part 2

2. Empowerment
objective - for
laypeople to have an
understanding of
the FUNDAMENTALS
and GENERALITIES in
the MEDICAL
MANAGEMENT of
GOITER – Part 2.
Health
Disorder
Course–
Fundamentals
and
Generalities in
Medical
Management
of Goiter –
Part 2
February 12, 2022
1400H - 1500H
Via Zoom

3. Empowerment
objective - for
laypeople to have an
understanding of
the FUNDAMENTALS
and GENERALITIES in
the MEDICAL
MANAGEMENT of
GOITER – Part 2.
Health
Disorder
Course–
Fundamentals
and
Generalities in
Medical
Management
of Goiter –
Part 2
ROJoson PEP Talk
I have a Patient
Empowerment
Program in which I
like to empower the
lay people or
patients to take
control in the
management of
their health.

4. There are 3 courses
in the PEP Talk.
I completed the Core
Course on October 9,
2021.

5. From October 23,
2021 onwards, I have
been tackling Health
Disorder and Health
Issue Courses. This
may take 3 years or
longer.

6. Empowerment
objective - for
laypeople to have an
understanding of
the FUNDAMENTALS
and GENERALITIES in
the MEDICAL
MANAGEMENT of
GOITER – Part 2.
Health
Disorder
Course–
Fundamentals
and
Generalities in
Medical
Management
of Goiter –
Part 2
My PEP TALK today
is entitled:
Fundamentals and
Generalities in
Medical
Management of
GOITER, Part 2. This
is part of the Health
Disorder Course.

7. Contents:
• What is a goiter?
• What are the common types of goiter?
• What are the causes of goiter?
• How common are the goiters?
PART 1
Fundamentals
and
Generalities in
Medical
Management
of Goiter

8. Contents:
• Clinical diagnosis of goiter
• Paraclinical diagnostic procedures for goiters
• Treatment for goiters
• Health restoration and maintenance
PART 2
PART 3
Fundamentals
and
Generalities in
Medical
Management
of Goiter

9. Fundamentals
and
Generalities in
Medical
Management
of Goiter
Definition of Terms in Title AND Delimitation of
Coverage of Talk:
Fundamentals – simplest and essential facts and
theories which can serve as a basis or foundation
and support for advanced information
Generalities – general statements of info, not
covering specifics and details
Medical Management – diagnosis and treatment
by physicians

10. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Clinical diagnosis means a conclusion or
decision made by a physician after
examining a patient and after evaluation
of the data on symptoms and signs.
Symptoms are what are felt and observed
by the patient or a person on the body.
Signs are findings of a physician after
physical examination of a patient.

11. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter

12. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Procedures in clinical diagnosis of goiter:
Patient has symptoms.
• Physician evaluates the symptoms to look for
cues for a goiter and then cues or pattern for a
particular goiter disease.
• Physician does physical examination to look for
sign-cues for a goiter and cues or pattern for a
particular goiter disease.
• Physician processes symptoms and signs to
determine 1) whether a goiter is present and 2)
if present, what is the goiter disease.

13. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Processes used in clinical diagnosis of
goiter:
• Pattern recognition
• Prevalence

14. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Processes used in clinical diagnosis of
goiter:
• Pattern recognition process means realization
that the patient’s presentation conforms to a
previously learned picture or pattern of
disease.
• Prevalence process means choice of a diagnosis
is based on the frequency of occurrence of the
disease in a certain locality, in a certain age and
sex group, and in the affected organ and
system.

15. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
• Lump/s on the front, base and central
part of the neck which moves up and
down with swallowing
• Lump/s on the side of the neck
• Palpitation
• Sudden weight loss
• Persistent fatigue
Common symptoms that will lead to
suspected presence of goiter

16. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Persistent fatigue
A cue or alert-signal for HYPOTHYROIDISM
Common symptoms that will lead to
suspected presence of goiter

17. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
• Palpitation
• Sudden weight loss
Cues or alert-signals for
HYPERTHYROIDISM
Common symptoms that will lead to
suspected presence of goiter

18. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
• Lump/s on the front, base and central
part of the neck which moves up and
down with swallowing
• Lump/s on the side of the neck
Cues or alert-signals for tumors which
could be benign or malignant (need more
sign-cues)
Common symptoms that will lead to
suspected presence of goiter

19. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After a patient tells me her/his symptoms
which may suggest a GOITER,
I examine right away the neck and check
the pulse rate.
I additionally gather other data as
indicated with the goal of more specific
and accurate clinical diagnosis.
ROJoson Way of Evaluation

20. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
Clinical Diagnosis:
Normal Thyroid
• Thyroid gland is not palpable.
• Thyroid gland is not enlarged.
• There is/are no nodule/s on the thyroid gland.
• There are no neck nodes.
• Pulse rate is less than 90/min (normal).
• No symptom-cues for hyperthyroidism and
hypothyroidism

21. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• The thyroid gland is palpable.
• The thyroid gland is enlarged.
• There is /are nodule/s on the thyroid gland.
Clinical Diagnosis:
GOITER
which has to be
evaluated further
for more specific
diagnosis

22. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• If the pulse rate is less than 90/min
• If the pulse rate is ≥ 90/min
Clinical Diagnosis:
NON-TOXIC
GOITER
TOXIC GOITER

23. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• The thyroid is diffusely enlarged.
• The pulse rate is ≥ 90/min
• Tremors
• Bulging eyes
Clinical Diagnosis:
TOXIC GOITER
HYPERTHYROIDISM
GRAVES’ DISEASE

24. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• The thyroid is diffusely enlarged.
• The pulse rate is < 90/min
• There is persistent fatigue.
Clinical Diagnosis:
NON-TOXIC
GOITER
HYPOTHYROIDISM

25. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
Clinical Diagnosis:
NON-TOXIC
GOITER
DIFFUSE COLLOID
ADENOMATOUS
GOITER
• There is a goiter.
• The thyroid is diffusely enlarged.
• The pulse rate is < 90/min
• There is adequate intake of iodine-rich foods.
• There is NO history of persistent fatigue.

26. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
Clinical Diagnosis:
NON-TOXIC
GOITER
IODINE-
DEFICIENCY
GOITER
• There is a goiter.
• The thyroid is diffusely enlarged.
• The pulse rate is < 90/min
• There is inadequate intake of iodine-rich foods.

27. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• The thyroid has nodule/s.
• The pulse rate is < 90/min
Clinical Diagnosis:
NON-TOXIC
GOITER
which has to be
evaluated further
for more specific
diagnosis
(cancer or NOT
cancer)

28. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• The thyroid has nodule/s.
• The pulse rate is < 90/min
• Positive for cues for malignancy:
• Hard nodule/s
• Fixed; hoarseness of voice
• Neck nodes / distant mass
Clinical Diagnosis:
NON-TOXIC
GOITER
THYROID CANCER
which has to be
evaluated further
for more specific
type of cancer

29. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• The thyroid has nodule/s.
• The pulse rate is < 90/min
• Positive for cues for malignancy:
• Hard nodule/s
• Fixed; hoarseness of voice
• Neck nodes
Clinical Diagnosis:
NON-TOXIC
GOITER
THYROID CANCER
PAPILLARY
CANCER

30. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• The thyroid has nodule/s.
• The pulse rate is < 90/min
• Positive for cue for malignancy:
• Distant mass suspicious for metastasis
Clinical Diagnosis:
NON-TOXIC
GOITER
THYROID CANCER
FOLLICULAR
CANCER

31. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
After examining the neck and checking the pulse
rate (and gathering other indicated data), I have
these possible situations:
ROJoson Way of Evaluation
• There is a goiter.
• The thyroid has nodule/s.
• The pulse rate is < 90/min
• NO cues for malignancy:
• Hard nodule/s
• Fixed; hoarseness of voice
• Neck nodes / distant mass
Clinical Diagnosis:
NON-TOXIC
GOITER
BENIGN
COLLOID
ADENOMATOUS
GOITER

32. Clinical Diagnosis of Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Disclosures:
I have been using ROJoson Way of Evaluation for
more than 40 years now.
My batting average:
>95% accuracy in my clinical diagnosis.
The <5% error I corrected right away with
paraclinical diagnostic procedure – to make it
100% accuracy in the end.
ROJoson Way of Evaluation

33. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter

34. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
The foremost indication for a paraclinical
diagnostic procedure can be stated this
way:
if you are not certain on the primary
clinical diagnosis and you need to be
certain or be more certain before
treatment, then go for a paraclinical
diagnostic procedure.

35. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
To decide on indication of the paraclinical
diagnostic procedure,
the physician uses two processes –
- degree of certainty on the primary
clinical diagnosis and
- comparison of the treatment plans for
the primary and secondary clinical
diagnoses.
As a rule, there is no need
for a paraclinical
diagnostic procedure if:
• you are quite
certain of your
primary clinical
diagnosis.
• treatment plans for
primary and
secondary
diagnoses are the
same.

36. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Procedures Benefit
(goal – to
be more
definite on
the
diagnosis)
Risk Cost Availability
Option1
Option2
Option3
If there is a need for a
paraclinical diagnostic
procedure, the
physician uses the B-
R-C-A processes.
B – stands for benefit;
R – risk; C – cost; A –
Availability.

37. Paraclinical Diagnostic Procedures for
Goiter
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Procedures Benefit
(goal – to
be more
definite on
the
diagnosis)
Risk Cost Availability
Option1
Option2
Option3
The physician gives or
lists the various
options of paraclinical
diagnostic procedures
and then gives data
on the BRCA.
With the data given,
the patient is asked
what s/he prefers.

38. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Procedures Benefit (goal – to be
more definite on the
diagnosis)
Risk Cost (PhP) Availability
Option1 accuracy 99% acceptable 4000 available
Option2 accuracy 90% acceptable 3000 available
Option3 accuracy 60% acceptable 1000 available
Example of BRCA
comparative analysis
of paraclinical
diagnostic procedures

39. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Common instrumental and laboratory diagnostic
procedures that can be used after the clinical
diagnosis of goiter:
• Thyroid function tests – FT3, FT4, TSH
• Imaging procedures – ultrasound, thyroid scan,
CT Scan, MRI, PET Scan
• Needle aspiration ± biopsy

40. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Competencies required of physicians managing
goiters:
• Know the uses and indications of all known
instrumental and laboratory diagnostic
procedures for goiter.
• Use as needed and indicated.
• Select the most cost-effective one.
• Know how to interpret the results.

41. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Thyroid function tests – FT3, FT4, TSH
to check level of thyroid hormones in the blood –
euthyroid; hyperthyroid; hypothyroid.
Indications:
• when not sure whether a patient has
hyperthyroid or hypothyroid
• when needed to have a baseline and follow-up
values to monitor subsequent medical
treatment

42. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Thyroid function tests
Interpretations:
• Normal FT4 and normal TSH – euthyroidism
• Elevated FT4 and below normal TSH –
hyperthyroidism
• Below normal FT4 and elevated TSH -
hypothyroidism

43. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Imaging procedures – ultrasound, thyroid scan, CT
Scan, MRI, PET Scan
Indication:
When needed to evaluate the structure
(ultrasound, CT Scan, MRI) and at times, function
of the thyroid gland (thyroid scan and PET Scan)
Choose the most cost-effective ones.
THYROID SCAN

44. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Imaging procedures – ultrasound, thyroid scan, CT
Scan, MRI, PET Scan
Indication:
Ultrasound, CT scan, MRI can be used to evaluate
the structure - size of the thyroid gland and
whether a nodule present is benign or malignant.
Choose the most cost-effective ones.

45. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Imaging procedures – ultrasound, thyroid scan, CT
Scan, MRI, PET Scan
Indication:
Thyroid scan using a radioactive isotope is used
primarily to determine whether there is nodule
that is hyperfunctioning or not.
Choose the most cost-effective ones.
THYROID SCAN

46. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Needle aspiration ± biopsy
Indications:
• When needed to determine whether a nodule
is solid or cystic (if cystic, needle aspiration
may be therapeutic in outcome)
• When needed to get a sample of solid nodule
for biopsy (whether benign or malignant - at
times the specific disease can be revealed)

47. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Competencies required of physicians managing
goiters:
• Know the uses and indications of all known
instrumental and laboratory diagnostic
procedures for goiter.
• Use as needed and indicated.
• Select the most cost-effective one.
• Know how to interpret the results.

48. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
There are several
issues to discuss in
the use of paraclinical
diagnostic procedures
in GOITER.
There are a lot of
confusion, not to say
errors, happening.
Issues:
• Ordering tests not needed for diagnosis of goiter
• Shotgun approach ordering every possible test just to
catch a specific diagnosis of goiter
• Inaccurate results
• Not knowing how to interpret results
• Using the fad, the popular one without comparative
analysis (benefit, risk, cost and availability) of other
options (usually with no considerations for cost-
effectiveness and patient preference)

49. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Issues:
• Ordering tests not
needed for
diagnosis of goiter
• Shotgun approach
ordering every
possible test just
to catch a specific
diagnosis of goiter
Ordering thyroid function tests and thyroid
ultrasound in one GO in one package for all
patients with GOITER.
- Shotgun approach
- Patients with nodules with no symptoms of
hyperthyroidism or hypothyroidism do not
need to have thyroid function tests
Rampant practices – not recommended!

50. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Issues:
• Inaccurate results
• Not knowing how
to interpret results
Results of paraclinical diagnostic procedures are
not always 100% accurate (there are percentages
of errors and non-conclusive results which must
be recognized by the physician-clinicians).
The physician-clinicians must know how to
interpret and evaluate the results and correlate
them with their clinical diagnosis and decide:
ACCEPT / HOLD / REPEAT!
A lot of times, physicians accept results as final.
Rampant practice – has to be remedied for patients’ sake!

51. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Procedures Benefit (goal – to be
more definite on the
diagnosis)
Risk Cost (PhP) Availability
Option1 accuracy 99% acceptable 4000 available
Option2 accuracy 90% acceptable 3000 available
Option3 accuracy 60% acceptable 1000 available
• Using the fad, the popular one without comparative analysis
(benefit, risk, cost and availability) of other options (usually with
no considerations for cost-effectiveness and patient preference)

52. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Example of BRCA
comparative analysis
of paraclinical
diagnostic procedures
Procedures Benefit (goal –
to be more
definite on the
diagnosis)
Risk Cost Availability
Ultrasound Indirect (2+) No pain P √
Thyroid
scan
Indirect (1+) No pain
+ Radiation
PP √
CT scan Indirect (3+) No pain
+ Radiation
PPPP √

53. Paraclinical Diagnostic Procedures for
Goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Example of BRCA
comparative analysis
of paraclinical
diagnostic procedures
Procedures Benefit (goal –
to be more
definite on the
diagnosis)
Risk Cost Availability
Biopsy Direct info (4+
diagnostic
yield)
Pain PPP √
Ultrasound Indirect (2+) No pain P √
Thyroid
scan
Indirect (1+) No pain
+ Radiation
PP √
CT scan Indirect (3+) No pain
+ Radiation
PPPP √

54. CONTENTS
• Clinical diagnosis of goiter
• Paraclinical diagnostic procedures for
goiters
Fundamentals
and
Generalities in
Medical
Management
of Goiter
Summary
Take Away
PART 2

55. Fundamentals
and
Generalities in
Medical
Management
of Goiter
Be always in touch with reliable medical
information on fundamentals and
generalities in medical management of
goiter.
Knowledge is power; it gives power.
Use the 4Ks of Patient Empowerment:
Kaalaman, Kakayanan, Karapatan and
Kapangyarihan
to gain greater control over decisions in
medical management of goiter.
Take Away in
relation to
Patient
Empowerment

56. Empowerment
objective - for
laypeople to have an
understanding of
the FUNDAMENTALS
and GENERALITIES in
the MEDICAL
MANAGEMENT of
GOITER – Part 2.
Health
Disorder
Course–
Fundamentals
and
Generalities in
Medical
Management
of Goiter –
Part 2