ROJoson PEP Talk: THYROID TESTS - Reading & Interpretation

1. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
reading and
interpreting
THYROID test results
in their health
management.
Health Issue
Course –
THYROID
Tests & Results
-
Reading &
Interpretation
July 30, 2022
1400H - 1500H
Via Zoom

2. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
reading and
interpreting
THYROID test results
in their health
management.
Health Issue
Course –
THYROID
Tests & Results
-
Reading &
Interpretation
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.

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

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

5. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
reading and
interpreting
THYROID test results
in their health
management.
Health Issue
Course –
THYROID
Tests & Results
-
Reading &
Interpretation
My PEP TALK today
is entitled: THYROID
Test Results -
Reading and
Interpretation.
This is part of the
Health Issue Course.

6. Contents of PEP TALK on THYROID Test Results -
Reading and Interpretation
• General recommendations on reading and interpreting
lab tests with numeric values and narrative descriptions
and conclusions
• How I read and interpret thyroid test results – thyroid
function tests and thyroid ultrasound
• Idiosyncrasies of radiologists in reading and writing
thyroid ultrasound results
• Examples of challenges in reading and interpretation of
thyroid function tests and thyroid ultrasound
• ROJoson’s advice in reading and interpreting thyroid
function test and thyroid ultrasound
Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation

7. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Thyroid function tests and ultrasound of the
thyroid are commonly done as laboratory
diagnostic tests for patients with possible thyroid
disorders.
A lot of Filipino patients have these tests done for
one reason or another, usually resulting from
screening fad or ordered by physicians who are
ritualistic and maximalist.
Then, they ask me to read and interpret the
results.

8. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
I am a minimalist physician.
I don’t subscribe to the screening fad of laypeople
as well as physicians who are usually ritualistic
and maximalist and who outrightly want to please
their patients with their desire for screening
laboratory tests.

9. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
I do laboratory tests only when indicated
(patients with symptoms and signs in which I am
not very definite with my clinical diagnosis that I
need help from laboratory tests; patients without
symptoms and signs but with a high risk for a
particular disease).

10. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
In my practice, I cannot avoid or refuse patients
coming to me for interpretation of the results of
their laboratory tests requested by themselves
and other physicians.
Because of the prevalence of these events, I have
decided to try to write something about them,
particularly to advise the laypeople on how to
read and interpret the results of the laboratory
tests.
For today, I will focus on THYROID tests.
I like to empower the
patients to know the
principles and
processes and
caveats of reading
and interpreting lab
test results.
Along the way,
hopefully, I can
convince them to
have lab tests done
only when indicated.

11. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
But before I go to the THYROID tests, allow me to
give you some important relevant introduction.
The thyroid gland is a butterfly-shaped organ
located in the base and central part of the neck.

12. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
The thyroid gland is a vital organ (vital organ –
one that is needed to survive) that regulates
metabolism, growth and development of the
human body. The thyroid gland makes, releases,
and controls thyroid hormones that control
metabolism. Metabolism is a process where the
food taken into body is transformed into energy.
This energy is used throughout the entire body to
keep many of the body's systems working
correctly.

13. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
If there is an abnormality in the thyroid gland, the
commonly used term is GOITER.
Thus, there is a GOITER when there is an
abnormality in the thyroid gland.

14. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
It can have abnormality in both structure and
function, singly or in combination.
• Abnormality in function (hyperthyroidism or
hypothyroidism – normal: euthyroidism)
• Abnormality in structure (either enlargement
or nodule formation)
• Abnormality in both structure and function
(combined or simultaneous)
Thyroid function tests
– diagnostic tests for
thyroid function
(euthyroid,
hyperthyroid,
hypothyroid)
Thyroid ultrasound –
diagnostic test for
structure
(enlargement, nodule
formation – benign vs
malignant)

15. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Usual thyroid function tests being done
nowadays:
• FT3 (free triiodothyronine)
• FT4 (free thyroxine)
• TSH (thyroid stimulating hormones)
Thyroid function tests
– diagnostic tests for
thyroid function
(euthyroid,
hyperthyroid,
hypothyroid)

16. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Usual interpretations of thyroid function test
results:
Thyroid function tests
– diagnostic tests for
thyroid function
(euthyroid,
hyperthyroid,
hypothyroid)
Normal Thyroid Function
(EUTHYROID)
• Normal FT3
• Normal FT4
• Normal TSH
HYPERTHYROID
• Elevated FT3
• Elevated FT4
• Depressed TSH
HYPOTHYROID
• Depressed FT3
• Depressed FT4
• Elevated TSH
Must be correlated clinically! (symptoms & signs)
There are reference
ranges (normal
values) for the
different types of
thyroid function test.
These reference
ranges have numeric
values.

17. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Usual interpretations of thyroid function test
results:
Thyroid function tests
– diagnostic tests for
thyroid function
(euthyroid,
hyperthyroid,
hypothyroid)
Normal Thyroid Function
(EUTHYROID)
• Normal FT3
• Normal FT4
• Normal TSH
HYPERTHYROID
• Elevated FT3
• Elevated FT4
• Depressed TSH
HYPOTHYROID
• Depressed FT3
• Depressed FT4
• Elevated TSH
Must be correlated clinically! (symptoms & signs)
If there are
incongruencies and
doubts, REPEAT
tests.

18. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
CHALLENGES in interpretations of thyroid function
test results:
Thyroid function tests
– diagnostic tests for
thyroid function
(euthyroid,
hyperthyroid,
hypothyroid)
Normal Thyroid Function
(EUTHYROID)
• Normal FT3
• Normal FT4
• Normal TSH
HYPERTHYROID
• Normal FT3
• Normal FT4
• Depressed TSH
HYPOTHYROID
• Normal FT3
• Normal FT4
• Elevated TSH
Must be correlated clinically! (symptoms & signs)
If there are
incongruencies and
doubts, REPEAT
tests.

19. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
CHALLENGES in interpretations of thyroid function
test results:
ZG, 66-year-old female, had thyroid function tests done as
screening (not ordered by me). NO symptoms of
hyperthyroidism or hypothyroidism.
FT3 low; FT4 normal; TSH elevated. I asked for a repeat.

20. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
CHALLENGES in interpretations of thyroid function
test results:
Repeat tests – normal FT3; normal FT4; and
normal TSH.

21. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
CHALLENGES in interpretations of thyroid function
test results:
If there were NO repeat tests, patient could have been
treated unnecessarily with medications, which can be
lifetime. She has normal thyroid function tests afterall.
She will have the unwanted lifetime anxiety of thinking she
has a thyroid disease.
Also, she may have a cascade of other unnecessary tests like
ultrasound and biopsy that may be needed to do further
investigations.
Fortunately, for her, a repeat test has prevented these
errors and other possible negative consequences.

22. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
CHALLENGES in interpretations of thyroid function
test results:
Another type of error:
Error in interpretation of hyperthyroidism based
on decreased TSH but without symptoms.
Repeat tests showed normal.
If not re-checked, patient could have been treated
erroneously for hyperthyroidism.

23. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Ultrasound of the Thyroid
(contains narrative descriptions of findings and
conclusions)
• Enlargement without nodules
• Enlargement with nodule/s
• Nodule/s (how many, location, size, nature –
cystic / solid / complex; border – distinct /
indistinct; tall vs wide ratio; calcifications; etc.)
• Presence or absence of enlarged neck nodes
Thyroid ultrasound –
diagnostic test for
structure
(enlargement, nodule
formation – benign vs
malignant)

24. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Ultrasound of the Thyroid - Conclusions
TIRADS = Thyroid Imaging Reporting and Data
System (For thyroid nodules seen)
• TIRADS 1
• TIRADS 2
• TIRADS 3
• TIRADS 4
• TIRADS 5
• TIRADS 6
Indications for needle
biopsy

25. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
TIRADS = Thyroid Imaging Reporting and Data System (For
thyroid nodules seen)
Tirads Definition Ultrasound features
1 Negative Normal thyroid
2 Benign Benign features
3 Probably benign Without suspicious features
4 A Low suspicion One suspicion feature
4 B Intermediate suspicion Two suspicion feature
4C Moderate suspicion Three or four suspicion feature
5 High suspicion Five suspicion feature
6 Known proved malignancy Confirmed malignancy
Indications for
needle biopsy

26. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
TIRADS = Thyroid Imaging Reporting and Data System (For
thyroid nodules seen)

27. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
TIRADS = Thyroid Imaging Reporting and Data System (For
thyroid nodules seen)

28. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Clinical Diagnosis (without ultrasound and thyroid
function tests):
• Enlarged thyroid without symptoms of
hypothyroidism / hyperthyroidism – DIFFUSE
COLLOID ADENOMATOUS GOITER
• Enlarged thyroid with symptoms of
hyperthyroidism – HYPERTHYROIDISM
• Enlarged thyroid with symptoms of
hypothyroidism - HYPOTHYROIDISM
Must be correlated clinically! (symptoms & signs)
Sharing with you
my experience with
clinical diagnosis
(without ultrasound
and thyroid
function tests) –
batting average –
more than 90%
accurate.

29. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Clinical Diagnosis (without ultrasound):
• Multiple thyroid nodules with no signs of
malignancy – MULTIPLE COLLOID
ADENOMATOUS GOITER
• Cystic / complex thyroid nodules – COLLOID
CYSTS / COLLOID ADENOMATOUS NODULES
• Solitary / multiple thyroid nodules with signs
of malignancy – THYROID CANCER
Clinical signs of
malignancy:
• Hard nodule (NOT
due to
calcifications)
• With signs of
invasion (fixed,
hoarseness)
• With signs of
spread (neck
nodes, distant
mass)
Options:
• Needle biopsy
• Outright operation

30. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
CHALLENGES
Lot of OVER-READING using the TIRADS
TIRADS = Thyroid Imaging Reporting and Data
System (For thyroid nodules seen)
• TIRADS 1
• TIRADS 2
• TIRADS 3
• TIRADS 4
• TIRADS 5
• TIRADS 6
Lot of needle biopsy

31. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
CHALLENGES
Illustration 1
ZC, 66-y-o female
In 2016, my clinical diagnosis was Multiple Colloid
Adenomatous Goiter. I have been following her
up for 6 years with the same diagnosis with no
biopsy.
One day, in 2022, she went for an ultrasound on
her own. Reading was TIRADS 5 for one nodule.
She had herself biopsy. It showed adenomatous
nodule. I WAS RIGHT AFTERALL.

32. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation

33. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation

34. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation

35. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation

36. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
ROJoson’s recommendations and advice in the
reading and interpretation of the ultrasound
results:
THE RESULTS OR DIAGNOSES ARE NOT FINAL YET
UNTIL SEEN BY A THYROID SPECIALIST-CLINICIAN.

37. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
In the reports issued by the radiologists, there is
usually a caveat statement to the patient
receiving the reports: CORRELATE CLINICALLY.
Or “This result is best interpreted by your
attending physician in correlation with your
clinical data, imaging and other laboratory
results.”
Clinical correlation means
gathering all other available
medical data and information
(such as age, sex, symptoms
and signs, other lab tests) to a
particular test to determine
their mutual or reciprocal
relations and to establish an
orderly connection (through
comparing and contrasting)
with the goal of coming out
with a clinical diagnosis that
is as accurate as possible.

38. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
My other recommendations:
• You can take a look and read the contents if
you want. However, as a layperson, chances
you will not understand and more so, interpret
the narrative descriptions and conclusions of
the certified readers. So, have the narrative
diagnostic reports read and interpreted by a
trusted physician-clinician or your attending
physician and let him / her make a decision on
the report.

39. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
• Even for the physician-clinicians or attending
physicians, they have to interpret the words or
phrases used by the certified readers and to
read between the lines.
• In addition, they have to correlate the findings
and conclusions of the readers with the
symptoms and signs, other tests and other
circumstantial situations that a patient may
have to make a decision whether everything is
normal; a finding is a mere biological variation;
something abnormal is being suspected;
and/or there is really an abnormality going
on.

40. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
• At times, they have to check the accuracy of
the reports and may have to have discussion
with the readers of the narrative diagnostic
reports.
• So, have the narrative diagnostic reports read
and interpreted by a trusted physician-clinician
or your attending physician and let him / her
make a decision on the report.

41. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
How I usually read and interpret the reports
As a thyroid specialist, these are what I usually do
in terms of reading and interpreting the
ultrasound reports:

42. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
I read the reports and take note first of any red
flags for cancer in the narrative descriptions and
conclusions.
I first look at the conclusions. If there is a TIRADS
conclusion, I take note of this first.

43. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
If there are conclusions for possible cancer, I then
look at the narrative descriptions and study the
bases for the radiologist’s making conclusions.
If bases are valid, then I tentatively accept the
conclusions. Tentatively, because I still have to
examine the patient’s neck. I still have to
correlate the reports with the physical
examination findings as well as other data and
information such as other tests done and also the
historical data.

44. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
If there are uncertainties or incongruencies in the
bases and in the reports, then, I examine the
patient, particularly the neck, and then make a
decision, essentially, whether to repeat the
ultrasound in another institution to be read by
another reader.

45. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
If the reports do not contain any red flags for
cancer, just the same, I do scrutiny of the reports
to check for any incongruencies. I also examine
the patient’s neck to correlate the reports with
my clinical findings.

46. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
So, whatever be the report, I CORRELATE
CLINICALLY.
I particularly examine / palpate the patient’s neck
(a must for all thyroid specialists) and then decide
and explain.
Clinical correlation means
gathering all other available
medical data and information
(such as age, sex, symptoms
and signs, other lab tests) to a
particular test to determine
their mutual or reciprocal
relations and to establish an
orderly connection (through
comparing and contrasting)
with the goal of coming out
with a clinical diagnosis that
is as accurate as possible.

47. Health Issue Course
BREAST
Ultrasound &
Mammogram
Results -
Reading &
Interpretation
How radiologists read and write their reports
One, there are a lot of subjectivity in the radiologists’ interpretations of
the findings in ultrasound. As a result, there are a lot of interobserver
variations, meaning, given the same ultrasound plates, two different
readers read and interpret them differently.

48. Health Issue Course
BREAST
Ultrasound &
Mammogram
Results -
Reading &
Interpretation
How radiologists read and write their reports
Two, the TIRADS is something recent in the Philippines. Not all
radiologists are adept in reporting using TIRADS.
THERE IS A LOT OF OVER-READING.

49. Health Issue Course
BREAST
Ultrasound &
Mammogram
Results -
Reading &
Interpretation
How radiologists write their reports
Three, radiologists commonly put recommendations after their
conclusions. Examples of recommendations are: tissue-biopsy; follow-up
ultrasound; etc.
My recommendation is just to consider them as personal
recommendation from the radiologists. We cannot stop them from giving
their personal recommendations.
One does not have to follow them. Let your thyroid specialist decide on
what to do next. The thyroid specialist may not also follow the
recommendations of the radiologists.
REMEMBER their CAVEATS: CLINICIAN TO CORRELATE CLINICALLY.

50. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
So, to emphasize, personally, whatever be the
report, I CORRELATE CLINICALLY.
I particularly examine / palpate the patient’s neck
(a must for all thyroid specialists) and then decide
and explain.
Clinical correlation means
gathering all other available
medical data and information
(such as age, sex, symptoms
and signs, other lab tests) to a
particular test to determine
their mutual or reciprocal
relations and to establish an
orderly connection (through
comparing and contrasting)
with the goal of coming out
with a clinical diagnosis that
is as accurate as possible.

51. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
ROJoson’s Advice with Summary and Take Away

52. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Summary
Take Away
Contents of PEP TALK on THYROID Test Results -
Reading and Interpretation
• General recommendations on reading and interpreting
lab tests with numeric values and narrative descriptions
and conclusions
• How I read and interpret thyroid test results – thyroid
function tests and thyroid ultrasound
• Idiosyncrasies of radiologists in reading and writing
thyroid ultrasound results
• Examples of challenges in reading and interpretation of
thyroid function tests and thyroid ultrasound
• ROJoson’s advice in reading and interpreting thyroid
function test and thyroid ultrasound

53. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Summary
Take Away
Although the reports are written for healthcare
professionals, not patients, there is a lot you can
learn by looking, studying, and learning from
them (especially after this PEP Talk).
In the end, however, always have a TRUSTED
thyroid specialist-clinician read and interpret
them for you.

54. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Learn how to palpate your own thyroid.
Do regular thyroid self-examination. You may
not need thyroid tests if you do regular
thyroid examination.
Do diagnostic tests only when indicated.
If you do diagnostic tests outside of the
indications, you will end up with a lot of false
positive alarming readings which can cause
undue anxiety; which may lead to other
unnecessary tests; which may lead to
unnecessary operations not to say expenses.
• Indications:
• To screen for a disease
or exclude its presence
in high risk patients
• To have a more definite
diagnosis after clinical
evaluation
• To determine severity
of a disease present
and to prognosticate (to
project outcome)
• To monitor progress of
disease and treatment
Summary
Take Away

55. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
At the end of the day,
Have a trusted thyroid specialist to review and
interpret and do a clinical correlation.
Summary
Take Away

56. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Summary
Take Away
After hearing the explanations and
recommendations on what to do next by your
attending physician, feel free to ask questions as
needed for further clarifications. The decision on
what to do next should be a shared one between
you and your attending physician.

57. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Summary
Take Away
If there is a need for a second opinion from
another physician on the conclusion and
recommendations on what to do next, go ahead.
You have the right to seek a second opinion. This
is part of patient empowerment. Knowing the
principles and processes of reading and
interpreting laboratory tests and their associated
caveats is also part of patient empowerment.

58. Health Issue
Course –
THYROID
Tests & Results -
Reading &
Interpretation
Be always in touch with reliable medical
information on how physicians read and interpret
thyroid function tests and thyroid ultrasound.
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 oneself by having
some idea on how physicians read and
interpret thyroid function tests and thyroid
ultrasound.
Take Away in
relation to
Patient
Empowerment

59. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
reading and
interpreting
THYROID test results
in their health
management.
Health Issue
Course –
THYROID
Tests & Results
-
Reading &
Interpretation
My PEP TALK today
is entitled: THYROID
Test Results -
Reading and
Interpretation.
This is part of the
Health Issue Course.