Physical examination and laboratory tests would be used to investigate a patient with thyroid swelling. Laboratory tests would include thyroid hormones (T4 and T3), TSH, and thyroid autoantibodies to check for hyperthyroidism, hypothyroidism, or an autoimmune cause. Radiological tests such as radioactive iodine uptake quantification and thyroid scintiscanning could further identify areas of abnormal thyroid activity that may indicate conditions like Graves' disease, multinodular goiter, or thyroid cancer. Together these examinations would help arrive at a diagnosis for the patient's thyroid condition.

1. HOW WOULD YOU APPROACH A
PATIENT WITH THYROID SWELLING?
DISCUSS THEINVESTIGATION YOU
WOULD LIKE TO DO TO ARRIVE AT A
DIAGNOSIS
MUHAMMAD HABIB NASUTION BIN
ZULPAN NASUTION
180028

2. Physical Examination
• Physical examination includes inspection and
palpation of the anterior and lateral aspects of
the neck to assess for thyroid enlargement,
presence of nodules, and lymphadenopathy.
• Asking the patient to swallow during palpation
can improve the detection of nodules.
• The signs of hyperthyroidism include tachycardia,
arrhythmias, muscle wasting, tremor, brisk
reflexes, and friable hair. The signs of
hypothyroidism include bradycardia, thickened
and puffy appearance of skin (myxoedema), and
delayed relaxation phase of reflexes.

3. • Visualisation of vocal fold movement is very
important if the patient presents with dysphonia.
This can be done with a dental mirror and a
headlight, or with a flexible nasopharyngoscope.
Vocal cord paresis or paralysis is a rare
complication of invasive thyroid cancer.
• However, the following characteristics portend a
higher risk of malignancy:
Nodules >4 cm in size
Firmness on palpation
Fixation of the nodule to adjacent tissues
Cervical lymphadenopathy
Vocal cord paralysis
History of ionising radiation to neck or upper
chest.

5. • For discrete nodules >1 cm in size and for smaller
nodules associated with high-risk features,
further evaluation should be geared toward
ruling out malignant causes, but it is important to
remember that the overwhelming majority of
thyroid nodules are benign.
• A solitary thyroid nodule is more likely to be
malignant (2.7% to 30% of cases) than is a single
nodule within a multinodular gland (1.4% to 10%
of cases).
• However, the overall risk of malignancy in a gland
with a solid nodule is approximately equal to that
of a multinodular gland, owing to the additive
risk of each nodule.

6. Laboratory Ix
• 1. Thyroid hormones (T4) & (T3)
• The lab could either measure total or free hormones.
• • Total T4 & Total T3
• RAISED in hyperthyroidism; DECREASED in hypothyroidism.
• BUT concentrations depends on binding protein conc = MAJOR
DISADVANTAGE.
• Ex: In hyperalbuminaemia, Total T4 & T3 are both high even though
pt is clinically euthyroid.
• Free T4 (fT4) & Free T3 (fT3)
• more reliable than total T4 & T3
• INCREASED in hyperthyroidism
• DECREASED in hypothyroidism
• In T3 thyrotoxicosis, only fT3 is raised whilst fT4 is normal.
• T3 measurement is of no value in hypothyroidism since it may be
normal due to increased peripheral conversion from T4.

7. • 2. TSH:
• • An index of thyroid function as TSH release is controlled thru
• negative feedback by thyroid hormones.
• • T4 and TSH are usually ordered together as Thyroid Function
Test
• (TFT)
Ix HYPERTHYROIDISM HYPOTHYROIDISM
1’ 2’ 1’ 2’
TSH DEC INC INC DEC
Free T4 INC INC DEC DEC
THYROID FUNCTION TEST

8. 3. Thyroid Autoantibodies
• • Use for ix of the cause of thyroid disorders
(autoimmune). Eg:
 TSHAb (bind to and stimulate TSH receptor):
 Graves’ disease
 – Anti-thyroid peroxidase (Anti-TPO):
present in almost all (95%) patients with autoimmune
thyroiditis
(Hashimoto’s disease) & also in Graves’ disease
• High titre indicate autoimmunity and may be a/w
present or
future oocurence of other organ specific autoimmune
disease.
• Anti-thyroglobulin Ab (AntiTG)
Also found in thyroid autoimmunity but in lower
frequency

9. 4. Thyroglobulin
• Normally present in circulation in small
amount.
• Useful only in f/u of pts with thyroid cancer,
in which elevation of
• previously suppressed conc may indicate
tumour recurrence.

10. Radiological Ix
Radioactive isotopes techniques
i. Quantification of radioactive iodine uptake.
ii. Thyroid scintiscanning :
• IV dose of radioisotope given & distribution within the
thyroid gland is determined using a gamma camera.
• Allows identification of ‘hot’ (active) or ‘cold’ (inactive)
or
potentially malignant) nodules in patients with thyroid
lumps.
• Can distinguish between Graves’ disease (uniformly
increased uptake), multinodular goitre (patchy uptake)
or an adenoma (single’hot ’ spot) in patients with
thyrotoxicosis, and detect aberrant or ectopic thyroid
tissue.