This document provides details on examining a patient with a thyroid condition. It discusses examining the patient's personal history, complaints, history of present illness, past history, family history, general examination, local examination of the thyroid, making a diagnosis, and investigations. Key points include examining for symptoms of toxicity, pressure, or malignancy based on the patient's age, progression of symptoms, and consistency of the thyroid on palpation. Investigations may include thyroid function tests, ultrasound, radioactive uptake scans, and fine needle aspiration biopsy.
Thyroid Swelling: A practical guide on writing and presenting a clinical caseMuskaan Khosla
Every book tells us how to examine and what to examine in a clinical case. But, no book tells us exactly how to write a sheet and how to word the case. Here is a practical example ! Hope it helps!
Thyroid Swelling: A practical guide on writing and presenting a clinical caseMuskaan Khosla
Every book tells us how to examine and what to examine in a clinical case. But, no book tells us exactly how to write a sheet and how to word the case. Here is a practical example ! Hope it helps!
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
A brief presentation regarding etiology , clinical features , and management of chronic limb ischemia. It was presented by our unit at Department of surgery , Patna medical college
This is a review for the USMLE Step 1 of Pathology. It contains anything you need to know for your exam in pictures, diagrams and tables. THIS IS A TWO PART SERIES, look for the first part.
- Thyroid approach regarding history and physical examination mainly from BROWSE.
- Done by: Dr. Anas Aljundi ( Medical school at Al-Quds University ).
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
1. Prof. Dr. Emam Fakhr
Prof. of general surgery AIN SHAMS
UNIVERSITY
Thyroid case sheet
2. Personal history
Name
Age : Age of the patient can aid to the provisional clinical diagnosis.
i.e. Thyroid swelling
Since birth e.g. cretinism with goitre.
Puberty e.g. physiological goitre, solitary nodule (papillary carcinoma)
25-35 years e.g. diffuse toxic goitre, SMNG
40-45 e.g. multinodular goitre ,follicular carcinoma, autoimmune.
50-60 e.g. anaplastic carcinoma.
Sex : Goitre is more common in female than male.
Residence : Nodular goitre is common in some localities than others.
3. Complaint
1-Swelling. (in the lower front part of the neck, either
painful or painless)
2-Toxic symptoms.
3-Pressure symptoms .
4-Metastesis (chest, bone,..)
4. History of present illness
Analysis of complaint & leading questions
1-Thyroid swelling
Onset
Sudden = hemorrhage in nodule in simple nodular goitre.
Acute = inflammation.
Gradual onset = simple nodular goitre, toxic goitre & malignant goitre.
Course
Progressive in (simple nodular goitre, toxic goitre).
Rapidly progressive in malignant goitre.
Stationary =physiological goitre.
Duration
Few months or even weeks in physiological goitre.
Relative long duration in simple nodular goitre.
Short duration in malignant goitre.
5. History of present illness
Relation of pain to swelling.
Pain then swelling=inflammation.
Swelling then pain= malignancy.
Painful thyroid swelling
Hemorrhage occurs within a nodule of nodular goitre.
Malignant goitre (local and referred pain).
Thyroiditis.
The presence of any apparent causes:
psychic trauma.
Drugs .
Residence of patient.
The effect on general condition. Malignant cachexia
,tiredness with toxicity.
Other swelling of the body. Metastasis in skull-ribs-sturnum-iliac
bones-lumber spine.
6. History of present illness
2-toxic symptoms:
Metabolic symptoms:
Increase appetite together with progressive loss of weight.
Nervous symptoms: (may be lacking due to antithyroid drugs)
More common in young age.
Insomnia.
Tremor.
Anxiety.
Disorientation.
Psychosis.
Thyrotoxic neuropathy (rare).
Acute thyrotoxic encephalopathy (very rare).
Seizures (with or without an underlying abnormality).
Neuropathy secondary to nerve entrapment by lesions of pretibial myxedema
Chorea and athetoid movements (rare).
Myopathy.
(Myasthenia gravis -- associated).
7. History of present illness
Cardiovascular symptoms:
More common in old age or cardiac patient.
Tachycardia.
Premature atrial and ventricular contractions.
Atrial fibrillation.
Congestive heart failure. (resistant to drugs)
Angina with (or without) coronary artery disease.
Myocardial infarction.
Systemic embolization.
Death from cardiovascular collapse.
Resistance to some drug effects (digoxin, coumadin).
Residual cardiomegaly .
8. History of present illness
Muscular symptoms:
The muscular symptoms vary from mild myasthenia to profound
muscular weakness and atrophy, especially of proximal muscle
groups.
Commonest muscle affected are
extra-occular muscles
quadriceps femoris
temporalis muscle
muscles of the back
9. History of present illness
Eye symptoms:
Staring or frightened expression
Lid reaction.
Diplopia.
Blurred vision due to inadequate convergence and
accommodation.
Chemosis, corneal injection, or ulceration.
Irritation of the eye or pain in the globe.
Exophthalmos (also produces mechanically a wide palpebral
fissure) .
Decreased visual acuity due to papilledema, retinal edema, retinal
hemorrhages, or optic nerve damage.
10. History of present illness
Vasomotor symptoms:
Cutaneous manifestations are nearly always present when hypermetabolism is significant.
The patient feels hot and prefers a cold environment.
The hand of the thyrotoxic person is erythematous, hot, and moist (sometimes actually dripping
wet), in a state of hot hyperhydrosis.
Flushing is also very common.
Occasionally diffuse pruritis or urticaria occurs.
Gastrointestinal symptoms:
The appetite is characteristically increased.
loss of weight.
Colic and intestinal hurry (diarrhea).
Indeed, the pattern of weight loss with increased appetite is nearly pathognomonic of
thyrotoxicosis
although it may occur in diabetes mellitus and malabsorption or intestinal parasitism.
11. History of present illness
Urinary symptoms:
Polyuria and occasionally glycosuria are seen in uncomplicated thyrotoxicosis.
Sexual symptoms:
In female : menorrhagia at first and oligomenorrhea and finally amenorrhea.
In males : impotence. (late)
12. History of present illness
3-pressure symptoms
More in malignant swelling
2 tubes (a)Esophagus: dysphagia
Rare in large goitre but in malignant goitre is common due to infiltration, here dysphagia is
persistent and progressive. And retrosternal doitre.
(b) Trachea: dyspnea
Large goitre which lead to pressure from one side or from both sides or from the front of
the trachea as in retrosternal goitre. or infiltration of trachea.
3 nerves (a) Recurrent laryngeal nerve (hoarseness of voice) in malignant and
retrosternal goitre
(b) Sympathatic chain (horner syndrome)rare, dry nose
(c) Internal laryngeal nerve (malignant chocking),
2 vessels (a) Carotid arteries –syncopal attack
(b) Internal jugular vein
-congestion of the face
-congestion of neck veins
-black out: fainting attacks on stooping forwards.
13. Past history
1. Psychic trauma.
2. History of treatment of thyroid disease.
3. History of thyroid operation.
4. History of previous radiotherapy.
5. History of goitrogenic drug.
15. Examination
1-General examination
Fasces (starring look, sweaty, irritable) in toxicity
Built-attitude-facial expression.
Blood pressure.
Pulse : Rate
Tachycardia in toxic goiter
Bradicardia in myxodema
Rhythm (regular, extra systole, regular irregularity , AF)
Character (WATER HAMMER PULSE)
Equality on both sides
Temperature: Hot hands and sweaty(in psychosis sweaty, cold)
Subnormal in myxodema
16. Examination
1-General examination
The scalp:
Metastasis (character of thyroid metastasis).
Parietal-solitary-fleshy-pulsating-functioning
Temporalis muscle atrophy in toxic goiter.
Hair loss in myxodema.
The face:
Eye brow: loss of outer 1/3 in myxodema.
Upper eye lid: buffness- ptosis.
Special eye signs.
17. Examination
1-General examination
Special eye signs:
Examination of the eye in toxic goiter, the following sings may be elicited:
Exophthalmos
Rim of sclera seen around the iris.
Assess by standing behind the patient and tilting head backwards. Examine the
protrusion of the eyeball in relation to the superciliary ridges.
• Mild:
widening of palpebral fissure due to lid retraction (Stellwag's sign)
lid lag may also be present
• Moderate :
actual bulging due to orbital deposition of fat (retro-bulbar fat)
absence of wrinkling of forehead when patient looks up (Jeffrey's sign)
• Severe:
intraorbital oedema with congestion, raised intraocular pressure and muscle
paresis resulting in diplopia (ophthalmoplegia)
22. Examination
1-General examination
Lid lag
Is a phenomenon probably caused by increased sympathetic tone in thyroid disease,
resulting in spasm in orbicularis oculi.
To elicit this sign the patient should be asked to fix on the examiner's finger, held at least a meter from
the patient, and not move his head. The examiner then moves the finger slowly upwards and downwards,
observing the movement of the patient's eyes and eyelids. Normally they should move simultaneously; in
lid lag the lid move more slowly than the eye.
23. Examination
1-General examination
Mobius sign
Weakness of convergence of the eye on looking to a very near object.
Stellwag sign (staring look)
Infrequent blinking.
Joffroy sign (rosenbach)
Absence of wrinkling of forehead skin as the patient looks upward.
25. Examination
1-General examination
Chest and heart:
Dullness of the superior mediastinum.
Metastasis.
Malignant pleural effusion.
Abdomen:
Liver and/ or spleen enlargement in thyroiditis and lymphoma.
Lower limb:
Edema (pretibial myxodema-heart failure) .
Back and skeleton:
To exclude metastasis.
26. 2-Local examination
Inspection
The normal gland is not visible. Inspection should never be hurried,
for it is a highly important method of obtaining information
regarding swellings of the gland
Site: In the lower front part of the neck.
Size:
Shape: diffuse-symmetrical
Irregular
Skin over :Skin moves with and on thyroid, if fixed to thyroid = cancer
scar-dilated-veins- ulceration or fungation
Special character:
Movement up and down with deglutition
Limited mobility in neoplastic infiltration or inflammation.
Pulsation: in the lower border
27. 2-Local examination
Diffuse symmetrical goitre. Bosselated surface in multinodular
goitre.
Enlargement of the left lobe.
Enlargement of right lobe.Enlargement of both lobes and isthmus.
29. 2-Local examination
Palpation
Palpation is best done from behind with the patient's neck slightly flexed to relax the
sternomastoid muscles. Using both hands, place the thumb upon the nape of
the neck. In this way, a considerable portion of the fingers come to overlie the
right and left lobes of the gland
The sternomastoid muscle may be pulled back with the fingers.
30. 2-Local examination
Confirm data seen by inspection.
Warmth.
Shape : Oval-rounded-oblong-irregular shape. (with diameter)
One lobe or bilateral.
Consistency:
Soft is normal
Firm - simple goitre, Hashimoto's thyroiditis.
Stony hard - carcinoma, calcification, cyst, fibrosis, Hashimoto's thyroiditis.
Woody and tender - acute thyroiditis.
Tenderness: suggests thyroiditis.
Mobility: Normally mobile (you can separate the movement of larynx from thyroid
carcinoma may tether the gland.
31. 2-Local examination
Surface:
When the gland is enlarged, determine whether its surface is smooth (as
is found in primary thyrotoxicosis and colloidal goitre) or bosselated
(nodularity)(characteristic of multinodular goitre).
Edge:
Try to determine definitely the shape and position of the lower limits of
an enlarged thyroid gland. (retrosternal goitre).
Well-define
Ill-define
Relation to the surrounding structures:
Skin
Muscle
Blood vessels
Trachea
Thrill on the upper pole of the gland.
34. 2-Local examination
Percussion
Percussion over the manubrium sterni, normally it is resonant. If
dull it indicats the presence of retrosternal goitre or mediastinal
lymph nodes.
Auscultation
Put a stethoscope on the gland, a systolic or even a machinary
murmur may be heared in case of highly vascular thyrotoxic
gland. Specially on the superior pole.
Arterial bruit & venous hump.
35. Diagnosis
Diagnosis
1- Anatomical diagnosis:
A) Is it thyroid swelling or not?
-anatomical site of thyroid
-move up-and-down with deglutition.
b) The swelling is located to one portion of the
gland or diffuse.
c) Solitary nodule or multinodular goitre.
36. Diagnosis
2- Pathological diagnosis:
The clinician must answer the following questions:
-Is it simple or toxic goitre?
-if simple, is it diffuse or nodular?
- if toxic , is it primary or secondary toxic goitre?
b) Is it malignant goitre or not?
c) Is it Thyroiditis?
d) Does the swelling extend behind the sternum?
Retrosternal goitre.
e) Is the swelling obstructing the trachea?
f) Is there is evidence of myxodema?
3- Associated conditions:
- heart failure (thyro-cardia)in toxic goitre.
- Signs and symptoms of metastasis:
In chest, bones, liver and in porta-hepatis.
37. Retrosternal goitre
Clinical data in retrosternal goitre:
1-Fullness in the suprasternal notch.
2-I cannot get below the lower edge of the swelling.
3-Dull manubrum sterni on percussion.
4-Dilated veins crossing the upper part of the sternum.
5-In severe cases dilated non-pulsating neck veins.
6-Fainting attacks on stopping forward.
7-X-ray soft tissue shadow in the neck and superior
mediastinum.
8-signs and symptoms of tracheal obstruction:(sense of
suffocation)
38. Malignant thyroid
Criteria of malignant thyroid:
1. age of the patient
2. Course and duration: increase rate of growth in short
duration.
3. Pain locally in thyroid and referred to the ear.
4. Hardness of part or whole of the swelling.
5. Loss of mobility of the gland.
6. Berry sign: the carotid tree not displaced backwards but
actual infiltration of the blood vessels.
7. Local pressure and infiltration:
1. hoarseness of voice
2. Horner syndrome
3. tracheal obstruction
4. dysphagia
8. lymph nodes enlargement
9. symptoms of metastasis
39. Investigation:
1-Thyroid function tests
To detect functional (hormonal) status of the gland.
↑T3, ↑ T4, ↓ TSH → toxic.
↓T3, ↓ T4, ↑ TSH → hypothyroid.
Normal T3, T4, TSH → euothyroid
42. Investigation:
B- Ultrasound:
Sonography detects the internal structure of the thyroid
gland and the regional anatomy and pathology without using
ionizing radiation or iodine containing contrast medium. The
procedure is safe, does not cause damage to tissue.
If cyst → aspirate
If solid → FNA biopsy.
43. Investigation:
3- Fine Needle Aspiration Biopsy of the
Thyroid Gland
Fine-needle aspiration (FNA) biopsy of the thyroid gland
is now an established, accurate diagnostic test that is
routinely used as the first step in the evaluation of
nodular thyroid disease.
Can differentiate simple from malignant thyroid
(papillary carcinoma- anaplastic carcinoma-
medullary carcinoma). But can not differentiate
follicular carcinoma from follicular adenoma.