141221L - COMMUNICATION SKILLS (HISTORY TAKING): THYROID CONDITIONS

Lecture for 4^th year medical students at the Faculty of Medicine King Fahad Medical City, Riyadh, on December 21, 2013

1.0 FUNCTIONAL DIAGNOSES

·        Hypothyroid (slow down)

·        Euthyroid

·        Hypethyroid (speed up)

2.0 BASIS OF DIAGNOSIS (+ and -)

·        History of presenting symptoms

·        Clinical thyroid assessment

·        Measurements of blood thyroid hormone levels

·        Antibody studies

·        Thyroid imaging (thyroid technetium nuclear medicine scan, thyroid ultrasound)

·        Thyroid fine needle biopsy

·        Pathognomonic signs (spot diagnosis)

3.0 STRUCTURED HISTORY

·        Demographic data: age, date, residence / water supply (iodine)

·        Presenting symptoms / signs: background, the 5 questions, previous episodes, current medication, consequences / disabilities

·        Risk Factors

·        Medical history

·        Surgical history:

·        Family history

·        Social history / habits: Usual diet , Smoking, Alcohol, Drugs including Analgesics, Occupation, education, hobbies, Marital status, social support, Living conditions

·        System review: cardiovascular, respiratory, gastrointestinal, skin, musculoskeletal (growth and development), reproductive,  sensory and nervous etc

·        Closing the interview

·        Summary: what are the main problems?

4.0 PRESENTING SYMPTOMS OF HYPERTHYROIDISM (thyrotoxicosis)

·        Skin: excessive sweating, itching, heat intolerance

·        Nervous: Increased irritability,  emotional lability, malaise

·        Cardio vascular: Palpitations, dyspnea

·        Musculoskeletal: weakness, tremor

·        Gastro-intestinal: increased appetite, thirst, vomiting, diarrhea, increased bowel movements, weight Loss despite a good appetite

·        Reproductive: menstrual disturbances, loss of libido, gynecomastia

·        Children: excessive height / growth

5.0 PRESENTING SIGNS OF HYPERTHYROIDISM (thyrotoxicosis)

·        Enlarged thyroid gland (goiter): diffuse (generalized) or focuses and nodular - Pressure effects: dysphagia, more for solids than liquids - Dypnea, chocking sensation - Neck pain due to inflammatory conditions - Malignancy: voice change die to laryngeal nerve infiltration, hard neck lymph nodes,

·        Cardiovascular: tachycardia, atrial fibrillation, warm vaso-dilated extremities, systolic HT, cardiac failure

·        Eye: Exophthalmos (proptosis), eye lid retraction (white sclera seen above iris when patient looks forward), eye lid lag (upper eye lid lags behind the eyeball when patient is asked to look at finger moving from up downwards), diplopia, ocular pareses, conjuctival edema

·        Musculoskeletal: Fine tremor of hands, muscle weakness (patient has difficulty rising up from sitting squatting position)

·        CNS: Looks anxious, cannot sit still, irritable, psychosis,

6.0 RISK FACTORS OF HYPERTHYROIDISM

·        Auto immune: Graves' disease

·        Toxic nodular goiter: multinodular, solitary

·        Acute thyroiditis - rare

·        Gestational thyrotoxicosis - rare

·        Neonatal thyrotoxicosis - rare

7.0 PRESENTING SYNPTOMS OF HYPOTHYROIDISM

·        Lethargy, somnolence,

·        Loss of concentration and memory

·        Cold intolerance

·        Parasthesia

·        Deafness and unsteadiness

·        Muscle and joint pains / aches

·        Angina, intermittent claudication

·        Un explained weight gain

·        Constipation

8.0 PRESENTING SIGNS OF HYPOTHYROIDISM

·        Hypothermia

·        Thyroid shrunken

·        Slowness and sluggishness

·        Voice: husky, deep

·        Skin: dry and cold, thick

·        Face: puffy with peri-orbital edema and bags under eyes

·        Non pitting myxedema

·        Tendon jerks have a slow relaxation phase

·        Cerebellar dysfunction with difficulty in balance

·        Reproductive: Menorrhagia, infertility, recurrent abortion, galactorrhoea

·        GIT: Intestinal obstruction, Paralytic ileus,

·        Peripheral edema

·        Hair: dry, coarse, brittle

·        Children: slow growth, poor school performance

·        Nervous system: coma, depression

9.0 RISK FACTORS OF HYPOTHYROIDISM

·        Congenital: agenesia, ectopic thyroid remnants

·        Defective hormone synthesis: iodine deficiency, drugs (anti thyroid, lithium, amiodarone, interferon)

·        Auto immune: atrophic thyroiditis, Hashimoto’s thyroiditis, post partum thyroiditis

·        Infective: post sub acute thyroiditis

·        Post irradiation / Post surgery

·        Tumor infiltration

·        Hypopituitarism

·        Peripheral resistance to thyroid hormone

10.0 SCORING SHEET (THYROID HISTORY)

Item	Gp1	Gp2	Gp3	Gp4	Gp5	Gp6	Gp7	Gp8	Gp9	Gp10
Introduction
Demographics
Presenting Complaints
Risk factors
Medical history
Surgical history
Family history
Social history
System review
Closing
Summary

NB: Score: 0=not done 1=done not well 2=done well