0:05 hello my dear friends of white Army welcome to this surgery comprehensive clinical class in today's surgery case presentation we have with us uh Miss chandana who is fourth year mbbs student at AJ Institute of Medical Sciences Mangalore presenting a case of thyroid swelling welcome to you Miss chandana and I really appreciate for volunteering to present this case thank you sir thank you and uh as mentor and teacher we have our own uh pattern of white Army who has been the face since the Inception of white Army uh who is a h of surgery at the prestigious uh Kim Hui also additionally he's a
0:50 principal now there and my guide as well our inspiration as well who has been a soul and soul support to the entire White System since the beginning uh Professor ganta sir welcome to you sir yeah thank you thank you and Sir chandana is my own student she was posted in our init and she presented one of the cases to me and it was brilliant it was she presented brilliantly so immediately I requested her you need to be mentored by Guru sir please present the same case to him and you will get learn much more than this and this will be it will be exposure to a seasoned examiner as well how to present to exam examiner and how to convince him how to like all those things he will learn better so I requested her and readily
1:38 she agreed and she is here sir please bless her with your all your experience and vast knowledge uh yes with mentor's permission we can start the presentation please Chand you please start the case okay sir uh good evening to everyone I'm presenting before you the case of a patient named Miss XYZ who's a 58-year-old female who hails from car she has completed education up to the 10th standard and she's a homemaker by occupation she came with a chief complaints of swelling in front of the neck since 33 years the patient was apparently well 33 years back when the obster noticed a swelling over the neck during her first pregnancy which was Insidious in onset gradually Progressive in size up to a
2:24 size of approximately 12x 6 x 3 cm there's no history of Rapid increase in size of the swelling and there's no history of pain over the swelling or any fever there are no symptoms suggestive hypothyroidism or hyperthyroidism there's no difficulty in breathing no difficulty in swallowing no history of horseness over the voice there's no history of other swellings in the neck or anywhere else in the body there's no history of any signs of metastasis the patient is not a known case of diabetes Melius hypertension tuberculosis asthma or any chronic conditions there's no history of irradiation no history of goitrogenic drug intake no history of blood
3:10 transfusion for anemia sorry there was a history of blood transfusion for anemia two years back for which five units of blood was given there's no history of any other surgeries in the neck she consumes a mixed diet with no significant consumption of any geogenic foods her appetite is good and her sleep is adequate the her bowel and bladder movements are regular and unaltered there's no smoking or alcohol history and no any other substance abuse history there are no similar complaints in the family and no similar complaints in the neighborhood there's no family history of any cancers she's a postmenopausal lady who has attained her menopause at 51 years her past Cycles were regular and there's no history of repeated
3:56 miscarriages her index is P3 L3 a0 and all the three deliveries for normal vaginal delivery with no complications and she has completed breastfeeding of onee duration for each of the children summary patient is a 58-year-old female who from carala presenting with swelling over the neck since 33 years first notice during her first pregnancy Insidious in onset and gradually increased in size up to the current size patient presents a new thyroid state with no compressive symptoms nor any signs suggestive of malignancy the patient has no significant medical comorbidities and shows no family history for swellings over the neck no uh stop here Chand yes sir sir
4:42 can you can you go back to the first slide please yes yes sir yeah uh since it is the undergraduate presentation I may a little different than what we talk to the postgraduates okay okay sir we expect the same presentation for the postgraduates but at the same time for undergraduates it has to be a little different way of discussion okay sir okay when you start with a presentation like this uh you are presenting as a female patient is it all right so no need of taking this XY Z because for any person putting these whatever in this format may not be a nice way of uh uh uh like presenting
5:30 okay sir okay so it's a 58 years female patient okay sir okay yeah that is conveying the message yes sir okay don't mention XY Z so it doesn't sound nice okay yes yes sir so otherwise remaining fine and instead of writing this in the format like this it has to be in the sentence format which you presented okay sir okay it should not be in 1 2 3 4 5 6 not like that so it has to be in the sentence format yes in a single sentence you will finish it off okay next slide next slide so this is the chief complaint you have mentioned okay so this is exactly what we expect for the underes means you have conveyed that her symptom is swelling in front of the neck okay
6:17 that's what you have conveyed that's what the patient complains of okay yes so instead of presenting as swelling in the neck so you have specified that she has noticed in front of the neck yes sir so if that is a case what is a commonest disease that comes to your mind when this is the chief complaint sir probably a thyroid swelling probably a thyroid swelling why not a lymph node swelling so it can be a lymph node swelling but since this the size was very big and she's a woman so I'm not talking about size and other only this slide I'm talking about with this Chief complaint of swelling in front of the neck what is your thinking sir we'll think whether it's midline or lateral no I don't want Theory see you have conveyed that swelling is in front of the neck so you said probably a
7:04 thyroid swelling which I have accepted yes sir now I say that why not liph not spelling how do you dispro it this only this SL okay um so in front of the neck so most probably it's it's coming in front of the neck on the anterior aspect so probably it's the swelling of the thyroid itself that I have accepted how will you disprove that it is not a lymph swelling so D questions are not same DTI no I am not understanding only this point you not even 33 I will come back to this 33 years later I will come back to that later I'm concentrating swelling in front of the neck that's all I'm concentrating you said thyroid I accepted yes sir I say
7:51 why not lymph node you have to prove that okay um so since 33 years it's keep that aside in front of the Mi say okay what do we expect is common sense or general knowledge of lymph node swellings are usually lateral swimming lateral he says it is in front of the me yes sir even though theoretically you people will answer that Delan no preal they will not come to such a big size and stay there for 33 years okay so and lymph node swellings are lateral swellings yes sir her complaint is a anterior swelling her complaint whether it is right or wrong we in the examination yes sir but her complaint is anterior swelling yes sir front neck front swelling so it is unlikely to be a
8:38 lateral neck the immediate next question which will be asked for the andet is what is the commonest neck swelling you see in practice enlarge lymph node sir exactly it's a lymph node swelling commonly what we see yes sir okay that is a commonest swelling not a gal not a thyroid swelling so with this sentence of swelling in front of the neck at this point of time you think that probably it is a thyroid Sol what she has now I'll come back to this 33 years what is that you got the information by taking history that it is for 33 years what does it convey to you so since it's been there since 33 years then most probably it's Ben and exactly stop there don't proceed otherwise you'll do wrong it convin that probably it is a benign
9:24 selling so with this Chief complaint without knowing anything else we probably it is a benign thyroids only what we are dealing with whether it is yes or no plus and minus points favor against we'll see further yes sir I hope you have made it very clear with this single that is why history taking is important so with a chief component of this only one sentence we thinking in terms of probably is a B9 thyroid selling in this particular patient of aged 53 years am I right yes sir next next slide okay you have conveyed that this was noticed when she was pregnant first pregnancy yes sir okay I did not get the
10:11 information when was the last pregnancy for this lady from this history I did not get the information yes sir yeah so actually her uh last child is uh 20 around 28 29 now so it's around 30 she's last the youngest one is of 20 years age now around 25 yeah yes sir okay okay okay okay so since then it is growing you said yes sir okay fine okay these points you have made it very short in for underes we want a little more elaborative history uh you have suddenly conveyed that in this history of no pain but no fever why did you
10:59 watch the history of fever for this lady sir pain just to rule out um sir fever I asked just to Ru any thyroiditis and pain if there was any malignant conversion as such okay uh see just like that asking we may accept for the underes but you have to have a reasoning for every word of History reasoning PES most of the thyro may not be associated with fever even though it is it indicating that there is inflammation going on it may be a tender selling but to have fever very unlikely yes the only explanation for a fever if you really want to substantiate even then we may not accept it thyroid opsis but I don't want to discuss thyroid opsis in this platform conveying all
11:47 wrong information best way is not to mention or not to take the history of fever in a anterior NE okay sir if the same would have been in the lateral side your history is incomplete unless you ask the history of fever and C yes sir because the calest swelling in the lateral side of the neck is a lymph node and the calest cause for the lymph node swelling is tuberculosis in India csis so your history is incomplete not cold absis tuberculosis don't don't mix up the issues okay lateral neck swelling I'm talking about so it has to be a lymp node swelling so history of f is a must in such a scenario but in this case history of your is not at all required okay I will not try to substantiate the history of f for undergraduates and
12:34 confuse them more I will not do that so just take it granted that if it anterior next swelling elic history of you is not okay sir okay and what was your intention of sudden or rapid increase in the size of the swelling so for sudden increase in size it can be two things usually it can either be sudden Hammer inside the nodule or it can be malignant conversion okay what is the difference between a sudden increase and a rapid increase so or are they same sudden means the onset like it's not Insidious it's sudden all of a sudden but rapid means the size is increased all of a sudden so it's a increased quantitative okay whatever you said I understood both are same the way you describ no because you use word in Rapid
13:21 explanation also sudden means at once rapid and Rapid is quantitative okay maybe rapid use a more shorter duration than sudden okay yeah you understood yes sir okay rapid has got a shorter duration than S yes sir s will have a little longer disease process rapid will have a very shorter very quick disase process the commonest cause for a rapid swelling is bleeding bleeding H the commonest cause for a sudden increase in the size is a malignance Mal so just remember this rapid B sudden likely that it is malignant yes sir okay I will not confuse you further for this yes sir
14:07 okay next slide okay you have mentioned this in a single word which we expect for the postgraduates but as an under gaget you need to know what are all the symptomatology of hyper and hypo yes sir if I give a choice to you to select one of them out of this hyp or hyper for a given case of anterior NE swelling which one you are interested to ask is it symptoms of hypothyroidism or is it symptoms of hyperthyroidism sir hypo is more common but hyper is probably more dangerous don't be a politician in answering medical questions they don't go hand in hand anyone select anyone yeah uh hyper sir why hyper so because
14:55 if there is thyrotoxicosis basically the features are there so the gland if it is very enlarged it must be removed okay in other words in other words what I expected in a given case of a goer we are talking about goer primary is next swelling we are talking about yes sir I want to combine that with symptomatology that is physiological aspects of the gland in a given case of go commonly associated physiological changes pertaining to thyroid is hyper thyroidism yes sir you got the point yes so whenever you have a case of G symptomatology of hyperthyroidism is more important yes sir more important so it may be associated with the guer case of
15:44 hypothyroidism associated with a G is very less likely okay you know why um first thing you understood my explanation yes sir yes sir okay you know why why hypothyroidism is very unlikely to be associated with the G because most of the hypothyroidism are following thyroiditis where gland will go for fibrosis it is almost like a atrop gland yes sir so they will not have a goer goer yes sir they will not have a goer so it is a if at all if you are expecting a physiological changes pertaining to a thyroid in a case of goer it is a
16:29 hyperthyroidism which is more likely this you will have why I'm putting more like mentioning this point is this is how the need neat exam questions are prepared in a form of the scenario what I'm asking now exactly okay they will give a scenario like this there is a patient like this with a symptomatology of hyperthyroidism e he likely to have a g there is a one more patient with a symptomatology of hypothyroidism easy likely to have a g a hyper thyroidism which is likely to have a GU versus hypothyroidism yes sir okay so this hyper is more important than hypo in a GU case yes okay all the symptomatology what all probably k each one of them if
17:17 you go on asking it takes almost one hour so what I insist I'll make it very short each one of them hyperthyroidism symptomatology you should know you should know the reasoning also why it happens yes if you say increase appetite loss of weight what is the reason if you say palpitation what is a reason if you say anxiety what is the reason yes sir if you say Tremors what is the reason excess setting heat intolerance muszle weakness what is that muszle weakness it's a proximal myopathy okay distal myopathy there are different reasons okay so all of this history of diarhea mentioned so all of them that itself is a big topic that is the
18:03 changes in hyper thyroidism so all of them you should be reading the theoretical aspects of that reasoning for each one of them it is very beautiful every symptomatology has got a reasoning and the explanation okay for that I insist that you should be reading the standard textbooks and know what exactly okay what is the reason for weight loss please remember at this point of time no thyroid cancers will have a weight loss any goer with weight loss please rule out hyper thyroidism than malignancy it's a dict because thyroid cancers are very unlikely to be associated with weight loss okay so that is how each one of them each one of them are
18:49 important okay yes sir then hypo thym symptoms you have mentioned and please remember they don't go opposite of that yeah opposite of hyperthyroidism symptoms are hypo no it is not like that they are different all of your mindset is opposite of hyper is hypo no it is not like that here weight loss here weight gain may be there may not be there okay so you have have independently the explanations for hypo and hyperthyroidism that is a theoretical aspect which I insist you should be reading okay yes sir one more here itself hyper thyroidism and thyrotoxicosis are they same or different no sir they're different how are they different sir uh thyro toxicosis is basically the clinical
19:35 manifestation of the increase thyroid hormones in the blood it need not be because of a thyroid cause but in hyperthyroidism it is because of a thyroid cause excellent for the first one any example you would like to give uh sir stroma overi okay and ectopic uh ectopic thyroid foch chromosoma no no no no don't mix up don't jump we talking about hyper is entirely different entity they may have like yeah symptomatology like this but it is not the same okay one more is thyrotoxicosis fasia that is thyro toxicosis secondary to drugs yes yeah drugs drugs drugs and iodin preparations Bia excessive
20:22 thyroxin supplementation also will induce hyperthyroidism excessive iodin intake may cause so Bia so drug induced hyperthyroidism yes you answered correctly to know the difference between these two entities okay this slide this is what I mentioned all of them all of you should should know the theory part of it next slide okay straight way concluded that there is compressive symptomatology you mentioned if given a choice in a case guer like this if you expect compressive symptomatology ology which is that commonest compressive symptomatology one can have so more than more than esophagus trachea I did not say Esopus
21:08 my question was which is that commonness so you should answer that tracha exactly so I did not say esophagus so I did not expect esophagus also so your answer should because most Anor is the Tre most an is the tree here okay but even then in a case of go if there is a tree symptomatology you should keep two things in mind this holds good for the under gadets maybe little more expect for the posts one thitis that is rytis you should keep second malignancy more so anaplastic cancers so in a case of Strider not change of voice I'm confusing in a case of Strider with a
21:53 keep these two possibilities rities and anaplastic cancer can this trer happen in a benign disease also so it can if it's a very large goer then it can cause compressive symptoms pressure secondary to what is the reason why they will have sper sir because uh uh it can cause pressure atrophy tracho Malaysia can not atropy it's a Malaysia Tre Malaysia softening softening of the Tre rings and Malaysia and a postural variation in The Strider so is a typical of for this to happen there are few points you should know one it should be a bobar disease it should be of a chronic duration it should be a large
22:40 gland and Bine disease yes sir so these are the four points which are required for triala anything out of this unlikely to have a triala again this will have a PG questions like they will give a scenario they'll put the causes and they will put one of the causes in this list would be thyroid cancer that is a ruled out answer okay so that is how it is so if there is trer something like this keep these possibilities only such for example this lady after examination if you feel it's a bobar disease already she has got a duration of 33 years she has every right to have Tri Malaysia in this patient yes sir so the The Strider history of
23:25 Strider history of postural variation in The Strider is a very important if there is a history of Strider yes sir so it's an important history in this patient okay which she don't have she don't have no no sir okay fine and and breathlessness and difficulty in breathing are not SE why sir um difficulty in breathing is uh the discomfort and breathlessness can be because of lung M metastasis just clear what I expect for the under gadgets fighter and difficulty in breathing are the symptomatology of upper airway disease breathlessness is a lower airway disease yes that is lungs since we are talking about thyroid
24:12 disease one could be metastasis second could be patient in CCF if she has thyroid toxicosis they result in breathlessness breathlessness causes for breathlessness firster obviously what we have mentioned in the beginning next SL so this all you have what is that no history of goitrogenic drug intake what are the drugs you asked for so goitrogenic drugs um basically am adone for anti if she was antihypertensive and sual uas and lithium and certain antiasthmatics um uh even interferons okay iodine preparations
24:58 also that is more common than what all you have mentioned yes sir cough syrup simple cough syrups which contain iodin yes sir C syrups yes okay longterm intake okay you mentioned history of transfusion of blood five bottles for anemia two years back H maybe this is what she said yes sir actually she told me she was feeling fatigue the reason for this is she had hemorrhoids so because of that she had anemia you're not mentioned in the history here hemorrhoids the surgeries I thought only pertaining the neck we should include and other surgeries are not required then why anemia did you mention here if you were concentrating only on the neck because father is present so surgery for no if you you should use logic
25:45 see when she was anemic blood transfusions were given there has to be some reason so that reason has to be sought from you okay what is the reason why blood transfusion is given yes sir Okay so did she under a surgery for yes sir she was operated 5 years ago you not mentioned you're not mentioned which is wrong yes sir yeah you are mentioning not in relation with the G but in relation with her anemia and blood transfusion yes sir means means examiner will appreciate that yes you have put your efforts to find out the cause for her anemia cause for otherwise can you explain anemia in a GU no sir actually I wrote it just took it out because I thought only the next surgery should be no no no no no wrong you need to mention the for anemia we will appreciate that yes you have put your effort okay to get
26:32 the reason for anemia and blood transfusions that to five units of blood means it has to be a serious problem what she had probably yes for five years yes exactly that has to be mentioned why why blood transfusion was given yes sir okay yes sir uh can you mention me any instances where patient may require blood transfusion in relation with thyroid so they can undergo hamage so it's one in 50 patients undergo hamage so please understand my question please understand okay I did not say anything I said PL can you huh plumber Vincent syndrome no in relation with thyroid I stopped I did not say anything further only thyroid I said yes
27:19 sir and blood transfusion I did not say disease okay H so commonest cause where patient may need blood transfusion in relation with thyroid okay what I expected is following surgery if a person bleeds yes sir po stop somebody answered here yes sir yeah vam see beautifully has answer he has put postop yes sir otherwise we don't we don't we don't need it's only the bleeding either during surgery or post patient may need blood otherwise then nothing to do with blood transfusions yes sir fine next slide and you mentioned no surgeries in
28:04 the neck in the past is it relevant in this case so since she will have to undertake surgery if there was some previous surgeries and it'll be uh previous surgeries you expect sir if this is recurrent thyroid recurrent that is there you would have presented in the history of present illness only yes sir yeah you would have presented back only like a story yes sir H okay you would have presented in the present history only fine okay next slide okay these are all routinely what you people mention okay uh anything apti sleep anything in relation with the thyroid diseases yes sir sleep uh if they have hyperthyroidism then they might have decreased sleep and if they have they might have sis if they have
28:50 hypothyroidism fine we'll go to next next slide yes fine you must be knowing what are the diseases which can have a family history positive yes sir like medular thyroid car very good it can be in association with men 2 a and Men 2 B okay and there are many other syndromes like Cowen syndrome familiar aratis polyposis syndrome mun alite okay okay fine fine next slide okay what will the relation with the menal cycles and the thyroid diseases sir when they have hypothyroidism then usually they have manoria and when they have hyper
29:35 thyroidism then usually they have olom manoria why what is the reason so for hypo for hyperthyroidism it's because TS is similar to the HCG subunit and for that is the reason why they'll have increased bleeding and for hypothyroidism for hyperthyroidism they have decreased um oligo manoria because since the smooth muscle contraction that time the uterus contract so there's decreased bleeding okay uh fine uh what I expect if you're little slow and if you understood the reasoning then you'll be able to answer better rather than being only fast uh in case of hyper thyroidism hyper excessive functioning you'll have a less TSH is it
30:22 not yes sir so and TSH LH and FSH all three are secreted by the pitutary single Lo okay yes and whenever something happens like this with a decreased a Associated FSH and LH also comes down yes so the action of these two hormones on the uterine activity comes down hence alom manoria yes sir the second reason for alom manoria in thyrotoxicosis TSH ultimately it is a unit which acts on the receptor level and the smooth muscles yes sir so whenever the T3 T4 increase t34 in thyrotoxicosis act on smooth musles that is utrine muscles utrine muscles are crisscross like this yes sir and the blood vessels goes in between the
31:08 crisscross fibers yes sir so whenever there is excessive contraction of this crisscross musle utrine muscle fibers they constrict utan capillaries or blood vessel inside resulting in Alig Al the opposite of this where there is no contract ability in hypothyroidism they bleed excessively yes sir okay so this is the reason don't you people should not bu heart what is the manal changes in hypo and Hyper you should understand so that you'll be able to give explanation next slide I felt this all deliveries V normal origin I don't know this sentence is looking very odd normal delivery okay
31:53 fullterm normal delivery simple to make it instead of I really f sentence was little Accord okay fine next okay in the summary I don't expect all of this in a summary slide summary means it has to be a summary maybe in a single format like probably with this symptomatology looks like a go of benign iology in you status yes sir okay fine examination now kishan anything you would like to perfect sir so far it's good sir yeah sorry pres sir yeah please sir
32:39 consent was taken and the patient was examined in a well lit room with adequate exposure the patient is calm and not anxious her Palms are dry and there are no Tremors um patient is moderately built and nourished her pulse rate is 78 beats per minute measured in the right radial artery which is of regular rate Rhythm character volume and all the peripheral pulses are felt with no radio radial or radio femoral delay her blood pressure is measured as 120 by 80 MIM of mercury over the right arm in sitting position her respiratory rate is 16 cycles per minute of thoraco abdominal type and she's a fi her height is 170 cm and her weight is 58 kgs and her BMI comes up to 20.1 palor is present there is no ioris
33:26 no cyanosis no in no lymphadenopathy and no edema there are no eye findings and no other swellings this is the image we'll go to local examination maybe General physical examination General physical examination okay yeah okay uh fine uh conscent these things are fine what are the idea of looking into the pulse in a thyroid soling so pulse if they have hyper thyroidism then there'll be uh increased cardio and bounding pulse can be there okay and even irregularities collapsing nature maybe irregular yes sir okay if the pulse is collapsing what do you expect in the blood
34:11 pressure um increase sir increase means sir I didn't get you if you say increase I say it is 200 by 180 ERS like that it be like that no sir both are increased no both systolic and diastolic I have given scenario as increased no sir systolic systolic will be increased so what is that they will have in the blood pressure If there is a TI cardia um so systolic will be increased diastolic means what oh okay if systolic is increased diastolic is normal what will be ultimately what is that I want to no contractility difference difference contractility and the what the difference between DBP called Ros
35:00 Ros has answered that pulse pressure yes sir pulse pressure okay so it is a systolic hypertension what they will have yes sir if it is a hyperthyroidism systolic hypertension yes so it will be 150 by 80 so wide pulse pressure p pressure to have a collapsing nature of a pulse one should have a wide pulse pressure that's why whenever we have a case of thyro toxicosis in the Examination for the under really we'll be checking whether you have checked the blood pressure you have measured wide pulse pressure or not we'll be checking this yes for underes yes sir okay not only knowing Theory we'll be checking whether really you have checked blood pressure or not in that particular patient if there is thyro toxicosis yes
35:45 sir okay and at this point you people should know how to check pulse how to check for collapsing nature of the pulse how exactly it is being done you need to know you will be asked to demonstrate if it is there in a given case you need to demonstrate okay not just answering the questions and getting the marks okay yes sir fine do you expect febil nature in a thyroid because you written temperature of Fe um most probably not sir unless in which probably most probably not but probably so thyroiditis or if they're under like an thy thitis I don't know why you are after thyroiditis I said no thyroid will not induce beginning yes sir not less
36:30 chance it will not okay sir somebody has answered OB that is also wrong I'm talking about febrile nature of the patient and thyroid disease so malignant conversion in the begin no malignancy will not induce fever wrong malignancy will not so hyper yeah somebody toxicos not just toxicosis it is a thyroid storm thyroid storm one of the component clinical component of thyroid storm is hypothermia hyperia it's called malignant hypothermia one of the component of thyroid storm yes sir in fact in the treatment modalities of thyroid storm one of the modalities
37:18 control of ice increased temperature there are method we will not go into the depth of that one of the component of treatment thyroid storm is controlling the core temperature yes so it is only that is a situation otherwise we don't expect this fewer business in gas next SL I don't know you people are like always mention sinosis clubbing is it relevant for a thyroid it is not relevant it is unnecessarily we'll be having so many unnecessary discussions okay yes sir can you mention because you brought here this also will be asked your P need can you answer One Nail condition in relation with thyroid disease thyroid acopy will have clubing
38:06 in case of thyroid acropachy in what disease what thyroid disease Graves yeah thyroid toxicosis okay acopy what is that called so uh thyroid acopy is basically uh in the digital around the digits there can be sub uh soft tissues swelling periostal formation and clubbing what about the nails what are those Nails called in in such scenario they called dirty nails oh yes sir yes sir dirty nails because they will have sertion over the nail dirt seats there over the between the sertion that's why they are so beautifully lab
38:51 and it is seen in thyro toxicosis okay sir okay dirty nails okay so otherwise we don't see many of these whatever you if there is a p in a thyroid what is it significance so there can be pre tial edema in hyperthyroidism what is the difference between preal edema and pedal edema so pedal edema we usually check on the lateral malus but this one is up against the tibia and it's nonfitting okay three TI that is called a mix Eda or the shin seen in thyrotoxicosis even though it is called mix Eda yes sir pre somebody wrote pre not in hypothyroidism it is in hyper thyroidism hyper what we are talking about is in case of thyroid toxicosis
39:38 with CCF CCF congestive if a person has developed CCF they will have a p yes okay so if a person has got breathlessness hypertension wide pulse pressure your general physical examination incomplete unless you have checked for p to Ru out CCF yes that is how they go hand in hand even though in this patient it is not relevant but just I'm mentioning for under graduates so these are the points they should go hand in hand okay yes now coming to local examination so this is the image yeah you just describe okay on inspection we see a single diffuse swelling of around 12 by 6 by 3 cm length breadth and height with three nodules one on the right L one on the
40:24 left L and one on the midline the swelling moves with delution the swelling does not move with protrusion of the tongue anteriorly extends from 1 cm below the hyoid bone to 1 cm above the sternal notch the lateral borders lie under the sternomastoid the lower border of the swelling is visible and the skin over the swelling is normal the surface appears nodular so may I continue yeah then we'll come back okay on palpation it's a non-tender swelling it's a non-tender single diffus swelling of 12 * 6 * 3 cm with three nodules one on the right L one on the left loobe and one on the midline it's a firm consistency and the lower border of the swelling is felt the surface is nodular
41:12 and the plane it situated in is deep to the Deep cervical fascia anteriorly it extends from 1 cm below the hyoid bone to 1 cm above the sternal notch the lateral border lies under the sternomastoid muscle the trachea is Central and the cared p is palpable on both sides Cocker test is negative on oscilation there is no Brew heard over the superior pole systemic examination this is all normal this is all normal systemic examination yes sir all normal okay next slide you have yes sir summary okay the patient is a 58-year female who HS from carola presenting with swelling over the neck initially noticed 33 3 years ago during her first
41:58 pregnancy which is Insidious in onset and gradually Progressive to a current size of 12 * 6 * 3 cmet with three palpable nodules which are firm inconsistency clinically in new thyroid state with no symptoms or signs suggestive of malignancy and compression and no retrosternal extension my provisional diagnosis would be multinodular goer in a you thyroid State showing no compressive symptoms and no malignant signs come back to the inspection uh don't know maybe maybe your Institute the few things accordingly probably you must have
42:44 written uh this inspector findings has to be like what is being taught for this examination of swelling okay like SI size size extent surface number added factors is movement with the de glutation and the lower body is made out or not made out okay this is what you need in the same order same order yes sir and you already committed in the inspection that the nodules are seen on the right L and the left L which is wrong on inspection they already committed okay okay you taken it granted that it is a lo oh yes sir wrong wrong so only the swelling is SE surface is no Okay so you don't know what it is at inspection level so don't commit if you
43:30 say low it has to be low it becomes a commitment so don't say it is it's not low seen there that's all one second where is the higher bone position surface marking so hyid bone um C because you described in relation with the H bone yes sir C6 C6 is behind you describing from anterior yes sir uh Sur if somebody ask you where is the nose nose is above the mouth both are seen from front yes sir you got the point so to say it is high you have to see you have to have surface marking so in other words what I'm talking surface marking of the high you know where is it if
44:17 somebody ask you not C6 I not asking a vertial level um so I'm not sure sir it's working okay the Bas is straight like this if you draw a line from the chin posteriorly to the neck exactly that is the area where the high bone is situated sir this is the high bone yes sir okay yes sir this is the hard bone even though anatomically thyroid has got a relation with the high bone both developmentally and anatomically while presenting the case of a go we don't take high bone as a reference yes because it is not seen yes sir okay that is not the reference to be taken and then second point no
45:03 thyroid sing grows above the high bone or above the thyroid cartilage yes sir yeah okay you know what is a reason why they don't grow above so the pre-trial fasia is not open on closed it is closed and then attached to the oblique line over the thyroid cartilage so they don't grow up so the high bone is not anatomical reference for any description of a thyroid sing yes sir okay it is not to be taken okay and presentation should be like I said no swelling surface lower border and once you say m of the delation lower border has to be mentioned whether it is seen or not seen yes sir and for this particular case shelling doesn't move the protogen of the tongue is
45:49 wrong there are few areas where you need to mention this point otherwise you should not mention in all the cases we don't expect this to move with the protrusion of the tongue yes sir such a big swelling staying there for 33 years yes sir so this test needs to be done please remember all of you whoever is attending for these points one swelling anterior swelling in a child smaller size midline or paramedian over thyroid or above the thid cartilage you got the point if a given shelling fits into to these criterias then check for and it has to be a movement the delation that selling should be moving with these criterias
46:35 yes sir then check for M with the protren of the tongue to rule out thyr if this given swelling doesn't fit into these criteria this test is not required so your case given case it doesn't fit into any of these yeah except mutation dation yeah sorry so don't check for this okay sir okay next case presentation I'll ask K whether you have done the same mistake by mentioning this protran of the tongue what about the consistency no sir firm sir sir on yes okay so these are on on inspection yes sir okay fine yeah in palpation consistency has to come last
47:21 okay sir yeah consistency has to come last for any given sing pal Petry finding consistency should be the last finding yes sir before that you should describe all the inspector findings so how did you Pulpit for the S so we go behind the patient and we use all our fingers three fingers on the thing and we ask them to slightly Flex their neck okay what is the reason so when you slightly flex your neck that time the strap muscles become relaxed so it's easy to palpate the ground not only strap Muses you st must because the shelling goes underneath anatomically yes sir underneath the sh okay how did you Pulpit for the lower border of the swelling so for lower border of the swelling we put our hand above the sternal notch and we ask them to swallow
48:07 and we feel whether it's felt or not okay it is not feeling the notch above the notch once the no once the lower B goes up whether you able to inate there put the finger down oh yes sir not into the notch yes sir where where did you Pulpit for the koted pulsations sir coted pulsation um we draw an imaginary line from the superior border of the thyroid and the anterior border of the sternomastoid basically against C6 on the transverse process so do you know it is C6 so that was just the marking but we do it between border and the that is anatomical location of that but palpation it is anterior surface marking what you said okay which kot you mean here sir which kot you mean what
48:56 palpated there are three carots are there what are those so you mean like common carot internal which carot you are PP common Caro not you mean kot common kotd you should be answering us that which kotd yes sir okay yes sir so it is a common kerotin whenever we talk about kerotin in relation with the thyroid anatomically it is a common kot which has got a relation with the thyroid yes sir okay coer strest it is discouraged to do on bed side yes sir okay okay not to be done not to be done okay fine next slide percussion was not required for this lady um no sir because there was no
49:41 retrosternal extension okay any other reason where percussion can be done over the sternum and parasal other than Retros gon so enlarge lymph node okay of um group seven lymph node in case of what thyroid diseases so medular thyroid Cara okay yeah medary and tary there can be a lymph node mass in the med with a secondary deposits okay secondary deposits okay somebody has WR flat bones inward in Mets yeah there can be sternal deposits but they may not cause dull node it is a mediational mass which D note okay Med Mass fine next
50:30 slide yeah in the summary slide now anything you want to okay summary slide uh here I expect again um like in a simple format yes sir okay yeah 58 years what you mentioned with the palpation and and with a no bilateral bobar noes felt in the examination okay diagnosis so multinodular yeah in new thyroid State that's all we expect there no need to mention that there no compressive symptoms and no malignant signs no need if it is there you highlight straight away as C if it is not there you already mentioned that it is a multi oror in your thyroid St so
51:16 in a thyroid selling both anatomical and physiological changes you should okay yes yes sir uh kishan shall we discuss the management because it's already 10 no no timee 15 minutes please sir we'll proceed with the management very important okay yeah what will you do Chand what will you next so for management in first investigations any differential diagnosis you would like to do if the question is [Music] asked sir it could be carcinoma thyroid carc because there are multiple bated surface we might so does that go in favor of cancer no so since it's longstanding multi can become folicular
52:04 carcinoma with your presentation are there any signs suggest your cancer clinically knows sir so if the question is asked what is your differential diagnosis what should be your answer see me asking questions nobody will prevent but you have to answer what is that you'll be answering so differential um you not be there every time okay it's always parting to your index case you can't give all the swelling DDS for every next swelling okay in your particular index case is there any like some symptoms or signs which are like comparable to each two other three conditions only then you can tell a DD
52:51 yes sir Heria thyro they're very straightforward cases yeah okay no DDS you can tell sir clinical DS yeah exactly sir I I don't feel giving any differential diagnosis for this case except multinodular go that also is a right answer okay s that's what we want to know how firm you are with your diagnosis yes sir okay fine yeah yes sir fine how will you proceed now sir for investigations um to confirm the diagnosis we'll be doing ultrasound and based on those findings we'll decide whether we want or not ultrasound guided fnac and then um also we'll be doing the routine blood investigations all of the things and first of all before doing ultrasound we'll do TS such analysis
53:37 which is the first to be derailed after that we can do a T4 analysis and even radioactive iodine uptake scan can be done and before surgery indirect lingos scopy also has to be pered okay uh somehow I don't know kishan accepts or not uh I whenever at least when I was a student I'm little like straightforward answers beating around like a political answers I don't know people who listen to it may look soing but at the same time I may not appreciate straight way for undergraduates what do we expect yes first test to be done is T yes sir okay to know the physiological status yes sir next you know the anatomy yes USG so is
54:24 it the thyroid gland or no yes yes it is a thyroid is it a unilobar disease bobar disease yes it is a bobar disease single Nole multiple no yes it is multiple Noles do they have any malignant nature on Ultras yes sir that's what you need to know I will not go into the depth for the under gadet what are all the sonological features of malignancy if you know it is excellent that is for the Post gadgets it's a must for the under gadgets also if you know it is excellent what are the sonological features of a okay taller than should know should know TS okay system yeah okay so that is a one then you said yeah USG defy to to know
55:11 that yes anything is it a benine disease or a malignant disease even though you're not suspecting malignance malignance yes okay in the sonography that is steroids along with the the findings in the thyroid little outside the thyroid that is kerotin and lyph nodes okay if it is there you will come to know so these are the must along with this if you can highlight that sir my investigation would be in the form of further diagnosis confirmation of my clinical diagnosis if it is in general I'm talking I'm not talking about in this disease yes to confirm the diagnosis to know the extent of the disease to know the fitness of the patient for surgery if my contemplation is doing surgery okay for the medical diseases yes under
55:57 these headings you should be evaluating any disease yes sir any disease yes sir okay and here in this particular case you mentioned technician scan it is yeah for the discussion sake yes for this particular case not required yes sir for this particular case please remember all of you if you're asking for a functional scan that is a radioin uptake scan what we are talking about in this particular scenario if you are suspecting a physiological change in a single nodule otherwise what I mean is a toxic nodule yes sir toxic nodule there is a single nodule on clinical examination with hyperthyroidism nuclear scan becomes a
56:44 must yes sir okay nuclear scan so in the present scenario uptake scan is for toxic Nole that is plumers disease or a solitary noodle with hyper thyroidism yes sir followed by as a treatment modality also that can be used with i131 just remember to make it simple for under yes sir otherwise don't bring radio optic scan in a thyro yes sir okay okay so if you if if you have done and there are multiple nodules on ultrasound and there nothing suggestive of a malignant nature of Noles and F is no G so what be the treatment for this patient so total thyroidectomy total thyroidectomy how do
57:31 you substantiate doing surgery for this lady so because um if it stays the same then there might be compressive symptoms or it might become toxic thyro toxic features might start or it might undergo malignant conversion it's been 33 years very good which is more likely among these three so uh compression symptoms very good so it is staying there for 33 years okay now she's 53 okay 33 years it is CH compressive symptoms are likely second is developing secondary thyro toxicosis if you are more specific you will gain more marks instead of just mentioning thyro toxicosis if she develops thyro toxicosis tomorrow is a secondary thyroid toxicosis and the third rarest
58:16 possibility is malignant developing malignancy if she develops malignancy unfortunately what is a likely malignancy you suspect a follicular thyroid POC Cy okay multinodular POC Cy yes sir is it a better version versus papillary or a worst version versus spary worst prognosis sir compared to not worst compared to only okay compared to these two okay yes yes so total thomy what are the common K I'll just make them simple for the under level what are the common complications following total thomy sir immediate complications can be h other complications after 3 to 5 days they can present with parathyroid
59:02 insufficiency okay there can be thyroid insufficiency and then recurrent thyroid toxicosis and the most there can be heness of voice following recurrent lenial nerve injury or external lenal nerve and Par parathyroid and they can have kids or scars and okay you to class inate postoperative late postoperative inoperative can only two things one is bleeding from the nearby vessels second thing is injury to the surround nearby structures mix up everything and tell hly okay inop one is bleeding from the Superior or INF arteries can happen or
59:48 maybe from the jugular vein if the middle thyroid tears into surrounding structures which you should be careful with that is a then immediate postoperative what all can happen react reactionary bleeding can happen reactionary bleeding parathyroid insufficiency okay so po you can't okay can mix up everything and answer that's what examiner expects you yes sir application of knowledge yes what is that permanent or a chronic hypoparathyroidism when do you label that for thyroidectomy so not sure if it persist whatever the hypo
1:00:35 parathyroidism which patient may develop if it persist Beyond 3 months months some books mention 6 months if it persists beyond that that is called permanent hypoparathyroidism or chronic hypo Paris okay when do you expect hypo Paris after surgery total thomy when do you expect per after around 5 to 7 days that is wrong okay 24 to 48 hours till that time whatever circulating calcium is there that will be sufficient for for maintaining the calcium activity so to manifest following injury or removal it is at 24 to 48 hours yes sir okay 24 to 48 hours what are the signs you will
1:01:20 look into in the postoperative period to diagnose hypoparathyroidism so basically initially there will be perioral mbling or tingling sensation and then signs of hypocalcemia which could be chastic sign or Tru sign is what we will check and they might complain of muscle pain or abdominal pain groon and Moes earliest one would be what you said the numbness around the mouth that is the earliest okay uh if you really sometimes we go into the depth of hypothyroidism for the Post gadites what exactly is the mechanism why only peral why there is a claw sign why there is chti sign so we go into little depth the reasoning for for manifestations in hypocalcemia that
1:02:06 you people can read up okay yes sir and you you should be reading what is the difference in external Lal nerve injury and the recurrent Lal nerve what exactly happens what exactly happens okay the person has got a trao Malaysia what happens um sir because of TR take your Malaysia softening of the Rings the Lumen decreases so they'll have difficulty in breathing so when when that happens when that you will notice so uh not immediately after some time it is immediately after EXT probation okay once everything you finish the anesthetic exate that Lumen will collapse and the person develops trer so immediately person needs reintubation yes okay it's a immediate
1:02:53 posttop that's why the dictum is the operating surgeon should not leave the patient immediately after the surgery see that patient is extubated look into the card movements see that the person is breathing nicely then only we should go for tea yes sir okay so possibility of this treal collapse is immediate post after EXT tuation that will be the Treach Malaysia sometimes it will be asked again how do you manage your answer should be reintubation first wait for few days try exova see whether patient is comfortable or not if a person needs intubation for 7 to 14 days after this then they may need
1:03:40 treos otherwise it can be managed with only endoral to 7 to 14 days yes sir okay that is a treatment for three yes sir uh just to conclude I'll uh can I share my slide yes sir CH please stop sharing the pp yes sir uh it is just to add to your presentation yes sir uh is the my my sles are see yes sir yes please make it full screen sir if possible
1:04:26 yes sir They Se okay sir sir just I'll go one by one just I'll take two three minutes whatever you people have presented till now for example the first cursor is SE my cursor is SE yes sir okay in this case what you said movement with the dlut protren of the tongue no this case really needs small yes sir yes like I said no definition for checking for M with the proten of the this lady even though she's a old lady she fits into that it is a small swelling midline swelling above the thyroid it has to be test has to be done M with the protrusion of the tongue which I'll show
1:05:18 you okay that is how it is and when you have been asked to do this test see that the mouth is kept open only the tongue should move in and out like a snake tongue yes sir patient should not be closing the mouth otherwise whole jaw moves so mouth has to be kept open only tongue should go in and out yes then you will be appreciating this movement that is a test for movement with protren of the tongue only selected cases you should be doing this test yes sir okay yes sir now coming to this case like you have presented like I said no you have mentioned it as Lo seen in the right L left L and the EAS wrong yes for example
1:06:05 if you three slides I have put different cases this you should be presenting it as a diffus my cursor is seen yes sir it's a diffuse swelling this case we should put it as swellings three swellings are seen 1 2 3 don't mention this as right L left L and the East must no it is a swelling on inspection three swellings motation or not this swelling midline swelling and on the right side left side there no swelling here in this case yes sir you got the point yes sir okay andly shape sir like it was proper no that is a wrong don't mention butterfly yeah I will highlight all of you whoever is listening listen to this
1:06:52 the butterfly shape of a thyroid is for a normal thyroid once the thyroid develops disease there is no butterfly sitting there normal thyroid is described as a butterfly sing once a disease develops this butterfly shape goes off okay don't describe as a butterfly shape swelling for any goal okay sir it's a normal thyroid which is described as butterfly is any one of these photographs they look like a butterfly no sir not these none of them none of them okay so why I put this you should describe it at three swelling this you describe is a midline swelling and the right side swelling this you should
1:07:37 describe it as diffus swelling this you should describe as a solid swelling above the thyroid cartilage that's why I have selected these photographs yes sir then you said movement with the digitation once you say the swelling moves with the digitation immediate the next presentation should be the lower border yes sir lower border is made out yes sir that's what you should be highlighting mentioning that yes the conclusion would be it is not going into the med there is no ret extension that's what you will be highlighting yes sir don't mention protrusion of the tongue movement for this delling big yes sir okay so these are the few points I just I wanted to show in this my slides yes sir
1:08:30 and uh that is one inevitable question Chand why it moves with the protion of like tongue and why it moves with Del glutation that is one UGI stock question any examiner there is one invariably asked question in any thyroid presentation okay you should know exact answer for those two okay
