This document discusses the clinical diagnosis of thyroid disorders through history, physical examination, and classification of thyroid conditions. It outlines the proper evaluation methods and signs that indicate the presence or absence of a thyroid disorder. Key points include examining the thyroid for enlargement, nodules, tenderness or fixation; checking pulse for tachycardia; and looking for signs of hyperthyroidism, hypothyroidism or thyroid cancer like exophthalmos, dwarfism, or dysphagia. Conditions are classified as diffuse or nodular goiters and diagnosed based on physical findings, pulse, and presence of symptoms. Malignancy may be suspected for hard or fixed nodules, invasion or metastasis.

1. Clinical Diagnosis
of
Thyroid Disorders
Reynaldo O. Joson, MD
1985;2001

2. Thyroid Disorders
Very common
in the
Philippines!

3. Clinical Diagnosis
of
Thyroid Disorders
Reynaldo O. Joson, MD
1985;2001

4. Clinical Diagnosis
Diagnosis based on
•History
•Physical Exam

5. Learning Objectives
•Proper utilization of methods of clinical evaluation
•Identification of patients with and without thyroid
disorders
•Nomenclature of thyroid disorders
•Clinical classification of goiter
•Physical signs of thyroid cancer

6. Proper utilization of
methods of clinical
evaluation

7. Clinical Diagnosis
Diagnosis based on
•History
•Physical Exam

8. Clinical Diagnosis
Thyroid Patients
Physical exam
more important than
history!

9. Clinical Diagnosis
Physical exam data
more reliable than
historical data!

10. Physical Exam
of
Thyroid Patients

11. Thyroid Patients
Physical Exam
•Inspection of neck
•Palpation of paratracheal area
•Palpation of lateral neck
•Pulse rate
•Looking for
•Exophthalmos
•Hoarseness of voice
•Distant mass

12. Low paratracheal mass that
moves with deglutition
suspect
thyroid
pathology!

13. Pulse Rate and Goiter
Less than 90/min
- nontoxic goiter
90/min and above
- to rule out toxic goiter

14. Hyperthyroidism Present
(+) Signs of hyperthyroidism
•Goiter
•Tachycardia
•Exophthalmos
•Bruit
•Tremor

15. Hypothyroidism Present
(+) Signs of hypothyroidism
•Goiter
•Dwarfism
•Slow body movements

16. Identification of Patients
With and Without
Thyroid Disorders

17. Thyroid Disorder Present
If thyroid gland has nodule or
nodules

18. Thyroid Disorder Present
If thyroid gland is abnormally
enlarged

19. Thyroid Disorder Present
(+) regional or distant mass
considered metastatic from
occult thyroid cancer

20. Thyroid Gland
•Normally NOT palpable
•Palpable yet normal
•very thin patients
•physiologic enlargement

21. Thyroid Disorder NOT Present
• Gland is NOT palpable
•PR less than 90/min
•NO metastatic mass

22. Nomenclature
of
Thyroid Disorders

23. When making a
diagnosis,
know the name of the
disease!

24. Colloid Adenomatous Goiter
• Diffuse colloid adenomatous goiter
• Colloid cyst
• Colloid adenomatous nodule
• Multiple colloid adenomatous goiter

25. •Hyperthyroidism
•Hypothyroidism

26. Thyroid Cancer
• Papillary Cancer
• Follicular Cancer
• Medullary Cancer
• Anaplastic Cancer

27. Thyroiditis
• Acute thyroiditis
• Thyroid abscess
• Chronic thyroiditis

28. Follicular Adenoma
Clinical Diagnosis
Follicular adenoma
vs follicular carcinoma
vs colloid adenomatous nodule

29. Clinical Classification
of
Goiters

30. Clinical Classification
• Diffuse toxic goiter
• Diffuse nontoxic goiter
• Nodular toxic goiter
• Nodular nontoxic goiter

31. Diffuse Goiter
All lobes almost
symmetrically enlarged
with NO nodule(s)

32. Diffuse GoiterNormal size
thyroid gland

33. Clinical Classification
NOT the same as
Clinical Diagnosis!

34. Diffuse Toxic Goiter
Hyperthyroidism

35. Diffuse Nontoxic Goiter
Diffuse Colloid Goiter

36. Uninodular Toxic Goiter
Hyperthyroidism
Multinodular Toxic Goiter
Hyperthyroidism

37. Uninodular Nontoxic Goiter
Colloid cyst
Colloid adenomatous nodule
Thyroid cancer
Chronic thyroiditis

38. Multinodular Nontoxic Goiter
Multiple
Colloid adenomatous nodule
Thyroid cancer
Chronic thyroiditis

39. Nodular goitersNormal size
thyroid gland

40. Diffuse goiter
Normal size
thyroid gland
Nodular goiter

41. Nodular Goiter
If one lobe is smoothly
enlarged, the other lobe
is normal.

42. Physical Signs
of
Thyroid Cancer

43. Suspect Malignancy
Nodular goiters
Solid nodule
Fixed nodule

44. Suspect Malignancy
Local invasion
Hoarseness
Dysphagia
Dyspnea
Skin infiltration
Regional spread
Distant metastasis

45. Clinical Diagnosis
of
Thyroid Disorders

46. Diagnostic Process
• Proper methods of clinical evaluation
• Identification of patients with or without
thyroid disorder
• Nomenclature of thyroid disorders
• Clinical classification of thyroid
disorders
• Physical signs of thyroid cancer

47. Thyroid gland
NOT palpable
NO nodule
PR < 90/min
No cancer signs (elsewhere)

48. Thyroid gland
NOT palpable
NO nodule
PR < 90/min
No cancer signs (elsewhere)
Normal thyroid gland

49. Thyroid gland
Diffusely slightly enlarged
PR < 90/min
Adolescent/perinatal

50. Thyroid gland
Diffusely slightly enlarged
PR < 90/min
Adolescent/perinatal
Physiologic goiter

51. Diffuse goiter
PR > 90/min
No cancer signs

52. Diffuse goiter
PR > 90/min
No cancer signs
To rule out hyperthyroidism

53. Diffuse goiter
PR > 90/min
No cancer signs
Exophthalmos

54. Diffuse goiter
PR > 90/min
No cancer signs
Exophthalmos
Hyperthyroidism

55. Diffuse goiter
PR < 90/min
No cancer signs

56. Diffuse goiter
PR < 90/min
No cancer signs
Diffuse colloid adenomatous goiter

57. Solitary nodule, NOT hard
PR > 90/min
No cancer signs

58. Solitary nodule, NOT hard
PR > 90/min
No cancer signs
To rule out hyperthyroidism

59. Solitary nodule, cystic
PR < 90/min
No cancer signs

60. Solitary nodule, cystic
PR < 90/min
No cancer signs
Colloid cyst

61. Solitary nodule, hard solid
PR < 90/min

62. Solitary nodule, hard solid
PR < 90/min
Thyroid cancer

63. Solitary nodule, NOT hard solid
PR < 90/min
LYTIC skull mass
NO dysphagia
NO dyspnea

64. Solitary nodule, NOT hard solid
PR < 90/min
LYTIC skull mass
NO dysphagia
NO dyspnea
Follicular cancer with skull metastasis

65. Solitary nodule, NOT hard solid
PR < 90/min
Ipsilateral neck nodes
NO dysphagia
NO dyspnea

66. Solitary nodule, NOT hard solid
PR < 90/min
Ipsilateral neck nodes
NO dysphagia
NO dyspnea
Papillary thyroid cancer with neck node metastasis

67. Huge thyroid nodule, fixed
PR < 90/min
(+) dysphagia
(+) dyspnea

68. Huge thyroid nodule, fixed
PR < 90/min
(+) dysphagia
(+) dyspnea
Anaplastic Carcinoma

69. Multiple nodules
PR < 90/min
No cancer signs

70. Multiple nodules
PR < 90/min
No cancer signs
Multiple colloid adenomatous goiter

71. Multiple nodules
PR > 90/min
No cancer signs

72. Multiple nodules
PR > 90/min
No cancer signs
To rule out hyperthyroidism

73. Nodular gland
NO discrete mass
PR < 90/min
No cancer signs

74. Nodular gland
NO discrete mass
PR < 90/min
No cancer signs
Chronic thyroiditis

75. Tender fluctuant mass, thyroid
PR > 90/min
No cancer signs

76. Tender fluctuant mass, thyroid
PR > 90/min
No cancer signs
Thyroid abscess

77. Diffuse goiter
PR < 90/min
No cancer signs
Short obese stature
Slow body movements

78. Diffuse goiter
PR < 90/min
No cancer signs
Short obese stature
Slow body movements
Hypothyroidism

79. Diffuse goiter
PR < 90/min
No cancer signs
Slow body movements

80. Diffuse goiter
PR < 90/min
No cancer signs
Slow body movements
Hypothyroidism

81. Diffuse goiter
toxic goiter common
Nodular goiter
toxic goiter rare