0:04 foreign good evening friends good evening all we are going to have a session today on examination of thyroid history taking clinical examination the basics began everything we are going to discuss today I hope I am horrible I'm just watching another thing
0:55 we are going to have a session yeah it's fine welcome all uh you can post your queries in the chat box I'm seeing in another device about the chat box so any clinical case before understanding and reading the clinical case finally students the most important thing you should do is to know everything about the anatomy because the last question if you have any trouble in the clinical presentation will be on an anatomy so it could be very thorough with the basics of anatomy so let me start with anatomy of thyroid gland okay anatomy of thyroid let us start so anatomy of thyroid gland is a very basic concept you should know what do you mean by thyroid what do you mean by
1:41 Tyrus Tyrus means what tairas is a word means Shield like I hope you would have seen in the movies the in doing the War uh welcome on welcome so the main movies they will be holding a barrier with a knife on with a squad on one hand and another one with the shield you know that Shield is known as thyrus so Shield means it protects it protects what does the thyroid gland protect what is the thyroid gland protecting here it doesn't protect anything here but there is one another structure which protects the neck structures they are thyroid cartilage okay please remember there is a cartilage known as thyroid cartilage so thyroid cartilage it's a very important protector of the
2:27 neck vessels thyroid cartilage is giving a covering for the Carotid artery ijiv and all the important now so thyroid cartilage is a shield since the gland is near the thyroid cartilage it is known as thyroid gland otherwise thyroid is not shielding anything it is just present as a gland in front of your neck since it is and near the thyroid cartilage it is known as thyroid gland so please don't forget the meaning of thyroid gland means it is derived from the thing that is known as Tyrus Tyrus means Shield right so thyroid gland is a butterfly shaped gland attached to the trachea with the histamous this is there are two lobes of thyroid gland right and left lobe so you should you will be knowing all those things so most important thing as a surgeon you should know is about the blood supply and the
3:14 nerves related to thyroid most important concept you are going to understand now so without I'm telling you again those who are joining late any clinical topic you should never discuss the clinical topic without understanding everything you read in your chaurasia Anatomy okay so you should go back to your anatomy books and read the anatomy before reading any clinical topic Let It Be hernia thyroid breast whatever case you are going to read node Anatomy so let me now explain about the vessels and nerves around the thyroid gland this is superior thyroid artery you can see Superior artery enters into the gland and then divides into branches so this is superior thyroid artery can you tell me from where does it come from it comes from
4:01 external carotid artery okay Superior artery comes from external carbon artery so it goes inside the gland and divides into branches inside the gland very important point so inferior third artery is C it is divided into multiple branches before entering the gland this is inferior third artery which is a branch from from where which is a branch from thyro cervical trunk it is a branch of tyroservical trial cough subclavian artery please don't forget that is inferior territory so there are two important major artery Superior and inferior artery and there is one more rarely seen artery that is known as arterial thyroidia Emma
4:46 which is a branch from arch of Iota so these are the basic three arteries you should not forget okay so this is very important for your exam what are the three arteries then comes thyroid veins the superior thyroid vein corresponds to superiorthal artery inferior thyroid vein corresponds to infinite thread artery that is one more extra vein that is Middle thyroid Wing So Superior thyroid vein joints with internal jugular vein middle thyroid Wing joints with internal inferior jugular vein and internal jugular vein and this is inferior thyroidane which joins into the brachials of aliquin and there may be one more way known as
5:33 Cocker swing that is a fourth vein of thyroid carcass vein is the fourth vein of thyroid it can join anywhere it is a variable a relation so it can join anywhere who is Cocker when you're reading a chapter on Cocker uh thyroid you should never forget about Theodore Cocker he is the first surgeon to receive Nobel Prize okay he's a first surgeon to receive Nobel Prize and please remember before Theodore Cocker dissected the thyroid and did the thyroid surgery the mortality of thyroid surgery is around 40 percentage the 40 percent of the people with the thyroid problems will die on surgery but after Theodore Cocker intervened in the thyroid the percentage of death has gone to less than one percentage now therefore he is
6:20 known as father of thyroid surgery please number is known as father of thyroid surgery please don't forget most important point for your example is a father of thyroid surgery he is a first surgeon to receive Nobel Prize we have so many places Cocker will be coming up in the surgery characterization manure and abdomen many places instrument carcass forceps etc etc he's having enormous application of caucus so this is the arterial Supply and Venus supply of thyroid so most important for your exam will be on the nerve supply of thyroid nerves Supply around the thyroid see this is the superior laryngeal noun okay this is superior laryngeal now it divides into two branches one is internal laryngeal
7:07 now another is external laryngeal now so these are the two nerves of superior laryngeal now branches there are two nerves Superior laryngeal now gives into internal laryngeal now and external laryngeal now so this is the vocal cord this is the vocal cords external laryngeal nerve is a pure mortar now please don't forget it is a pure moderna internal laryngeal now is a pure sensory now so internal and laryngeal nerve supplies New Cosa above vocal cards this is very important point so what is the supply of internal arrangelo IT Supplies mucosa above vocal cords so inter external laryngeal nerve supplies only one muscle it is a pure motor now so it will only Supply One muscle known as
7:54 thyroid muscle so can you tell me what is a function of cricuteride muscle it is a tensor of vocal cord please don't forget it is a tensor of vocal cord this is the now which is important for you to shout if I'm going to shout The Voice the picture of my voice is raised because of this muscle cricothyroid muscle so if external laryngeal nerve is gone during surgery you will land up in huskiness of wise askiness of voice also known as laws of Timber of Voice or loss of pitch of wise so if I try to shout my voice will not come only air will come that is what called as huskiness of voice so crico thyroid is very important so please
8:40 don't forget internal laryngeal now supplies mucosa above vocal cords so therefore if internal laryngeal nerve is injured what will happen to the patient they will have paroxysmal cough paroxysmal nocturnal cough they will aspirate when they lie down they will aspirate when they are awake they won't aspirate but when they die down the pooling of saliva will aspirate into the tracheon cause nocturnal cough and aspiration is seen because of internal laryngeal nerve injury so internal laryngeal nerve is pure pure sensory now external now is pure pure motor now please don't forget this and among the various nerves we are going to drill in thyroid the most
9:26 common nerve injured is most common nerve endure this one external angel now please don't forget most common navigation so we should be very careful when we are ligating the superior thyroid artery we should not injure the external laryngeal now so then coming to the other important now that is recurrent laryngeal now why it is known as recurrent you should understand what is the meaning of record and it is a branch of Vegas now it is a branch of vagus now so as a vagus nerve is going down as it is going down Vegas now can directly give a branch like this but this fellow will not give a branch like this it will go down the Vegas now goes down and from
10:12 here the recurrent the recurrent level now will arise go down and hook out and come back like this so it goes down and recurs to thyroid gland so it is going down and recurring and coming back to the thing is known as recurrent laryngeal noun so right recurrent laryngeal nerve laryngeal now hooks around arch of Iota please don't forget there's a basic McQ as well as fiber question level hook around the right subclavian artery left tracker and lavender will hook around the arch of Iota so left tracker and laryngeal now cooking around the arch of Iota so left tracker underneath now cooking
10:58 around the arch of Iota therefore it is having a long course which among these two nerves is having long causes left tracker and derangelo has long course so right recurrent laryngeal now has short course which will not go down directly come from the Vegas now like this is right recurrent laryngeal now is right recurrent laryngeal nerve is non-recurrent please remember very interesting McQ point from Billy in two percent of the people in two percent of the people it will not go down to the subclavian artery it will directly Supply the thyroid gland so non-recurrent recurrent laryngeal now
11:45 non-recurrent recurrent laryngeal now is most common on right side it is seen in two percent of the individuals so these are very important Anatomy related aspects so please don't forget the anatomy of thyroid gland so I'm going to discuss clinical examination but before going to clinical examination I want you to be having a broad outline of the anatomy of thyroid gland so now in this Anatomy itself I'll complete one surgical aspect during thyroid surgery I will be ligating superior thyroid artery very close to the gland like this to avoid injury it is allow you can see here I will ligate it very close to avoid injury to the external laryngeal nerve old concept is I used to ligate inferior artery away from the gland like this yes I used to like it away from the gland to prevent injury of recurrent
12:31 laryngeal now but what happened when I'm ligating away from the gland can you tell me why we have changed the concept of ligating away from the gland to ligating now close to the gland even inferior theradority is ligated in small small branches close to the gland because inferior thyroid artery is also supplying not only thyroid gland also the parathyroid gland so parathyroid Supply is from inferior artery if I ligate it away from the gland parathyroid will lose its blood supply so to supply the parathyroid I have to ligate it very closely so please don't forget this point so therefore it has to be ligated very closely please don't forget this important essential point for your exam so that I write recurrent laryngeal now and left
13:18 the questions which can be asked for this in from from this for your exams is where will you ligate the right recurrent laryngeal now inferior thyroid artery right side inferior thyroid artery ligated close to the gland both right and left inferior are getting close to the gland left and right Superior thorough artery is also ligated close to the gland so Superior artery ligated close to the gland to prevent the injury to prevent injury to external laryngeal now whereas infinite arteries I get it close to the gland to preserve blood flow to to preserve blood flow to the
14:04 this is very important point I want you to remember for your exams so this high yield topic please don't forget about the anatomy of thyroid glands any doubts you have from anatomy of thyroid gland because I'm now going to the real clinical examination of thyroid gland so any doubts if you have please tell me any doubts you have an anatomy of thyroid gland please tell me because this is most important without knowing the anatomy of thyroid gland you cannot answer most of the questions so now let us start with another important anatomy of thyroid gland is please don't forget this Anatomy is more important this is the thyroid gland and this is hyoid bone okay this is the high bone and now this is the arch of Iota this is a arch of Iota now I am going to draw
14:49 one important fascia from the arch of Iota that is a deep cervical fascia which is deep cervical fascia which is going up and now it is known as pre-trachial fascia as this fascia is going up it splits and and Engels the thyroid gland like this it splits and engulfs thyroid gland like this and anteriorly as well as partially the cervical fascia pre-trachial fascia engulfs and gets attached with the hyoid bone like this very important Anatomy this is pre-trachial fascia which invades the which invades the thyroid gland and angles their gland and attaches to the
15:35 high bone so when this is engulfing like this the posterior medial attachment of this gland I am now drawing a posterior medial attachment of this fascia this is known as what ligament the posterior medial attachment of this fascia is known as berries ligament please remember it is known as berries ligament berries ligament is a posterior medial thickening of pre-trachial fascia so this is a very important reason for movement of the gland with movement of gland with deglutation is because of this this you should explain the examiners when you are telling this is a thyroid swelling they will immediately ask why why do you say uh when you ask this the examiners will
16:21 immediately ask why do you feel this is thyroid gland you should tell on movement with deglutation it moves up so on movement with the regulation it moves up because why it is moving in degradation because of the pre-trachial fascia attached from the hyoid bone to Arch of Iota this is fascia extending from hyoid bone to Arch of Iota this is another interesting reason if the thyroid gland enlarges it cannot go more up you can see if a thyroid is using any patient coming to a gland swelling with the mouth it is swelling extending into the neck to the face no it cannot extend above the hyoid bone but it can extend into the mediation up to the arch of Iota that is a reason for retro sternal extension of thyroid retro sternal
17:09 extension of thyroid because of the huge enlargement can go up to a higher but not above the high bone please remember this okay so very important Anatomy Point pre-trachial fascia related Anatomy point and that is a question from basil Jose about the recurrent laryngeal nerve Anatomy with territory so parathyroid gland and recurrent laryngeal now are very very very closely related Anatomy be careful when operating because so this is the recurrent laryngeal now as it is going up recurrent laryngeal now is inferior parathyroid gland please remember inferior parathyroid gland is seen Superior to recurrent laryngeal now
17:57 Superior to recurrent original inferior parathyroid gland is seen superior to the current level whereas in this is superior parathyroid gland is a superior parathyroid gland which is seen behind recurrent laryngeal now behind recurrent laryngeal law so which gland when you try to remove you can injure the rectal language along because when I try to remove Superior paragraph gland injury to recurrent laryngeal now happens when I am trying to remove the superior parathyroid gland so inferior parathyroid gland is superior to the recurrent living alone and Superior Paratha gland is yellow that is why when I am doing uh four gland removal in case
18:44 of parathyroidectomy in case of hyperplasia which gland will you remove will you leave so when I am removing three end of gland three end of gland is removed in one surgery known as para bilateral cervical exploration surgery for parathyroid hyperplasia in this operation bilateral cervical exploration operation you will leave inferior parathyroid off of the gland in future if there is an enlargement I can approach and I can remove so in the removal of three end of gland which one will be left is left inferior parathyroid is left so that I can remove it if it enlarges in future without disturbing the recurring laryngeal nerve so when I tell about
19:29 recurrent laryngeal now you should know what is the most common site of recurrent laryngeal now injury okay now I am going to tell you some eight McQ points of recurrent laryngeal now please especially finally students most common site of recurrence yellow I'm going to tell you eight McQ points of recurrent laryngeal now so most common site of record welcome Raj welcome so what is the most common site of recurrent laryngeal now injury recurrent laryngeal now commonly gets injured that beers triangle beers triangle is bounded by tracheo esophageal group inferior thyroid artery common carotid
20:15 artery it is a triangle formed by tracheoesophageal group inferior third artery and common carotid artery and this triangle is the nerve gets injured at the cricothyroid uh as it enters the cricothyroid that is as it enters the trachea in this triangle as it enters trachea it gets commonly injured so please remember the most common site of recurrence now injury is Bear's triangle from Alien law it is bounded by tracheoesophageal group inferior thyroid artery and common carotid artery forms this triangle of BS triangle I'm going to tell eight points of rectangular law so right recurrent laryngeal now hooks around
21:02 yes around arch of Iota a left recurrent laryngeal now hooks around right subclavian artery which now can be non-recurrent sorry left tracker and laryngeal now hooks around arches right tracker and laryngeal now can be a non-recurrent okay can be a non recurrent laryngeal now so please don't forget which now can be a non-recurrent laryngeal now is asked as a PG entrance McQ so that you should not forget you should not forget this right side recurrent laryngeal now can be a non-recurrent recurrent laryngeal now in two percent of the people so most important McQ from ENT what is
21:47 the function of recurrent laryngeal now function of recurrent laryngeal now please don't forget it supplies the mucosa IT Supplies the mucosa below the vocal cords this is it is both having sensory and motor IT Supplies the mucosa below the vocal cord and another important function is it is also having motor function IT Supplies below vocal cards and motor to all the muscles of vocal cord motor to all muscles including posterior trichloride which is also known as safety muscle of larynx which is also known as safety muscle of larynx is the safety muscle posterior cricoid knife therefore injury of recurrent Arrangement now what will happen
22:33 okay so yes it is the same place where the berry ligament is attached it's correct it is the same place um Bears triangle is actually the correct answer if you want to test in the answer the example but it is the same place where the berry ligament is attached let me tell you the point McQ point from uh from Bailey and now let me read out the line in billion now you see the line in terms of surgical Anatomy the nerve can be located in the trachea reservical group where it forms one side of Beer's triangle the nerve will be normally uh seen here this is the point at which the nerve is most risk of injury during surgery it is nothing but the same very silicon attachment point so berries ligament attachment point or beers triangle both are same so very segment
23:19 attachment point and Bs triangle both are same you can tell both the answers are correct okay both answers are correct So Below vocal card and motor to all muscles it causes hoarseness so please don't forget what will happen to the injury of this recurrent laryngeal now so I hope you are clear with the basics let me now start with the clinical examination of thyroid so this is actually a final year topic this is a discussion chapter for final mbbs students and those who have entered finally are now recently after completing pre-fine layer so for our next exam as well as
24:06 for uh any of the exams this clinical examination topics will be very helpful so let us start with a clinical examination and history taking of history taking of thyroid gland very simple you should never mug up is still taking I always see when the students going for the exam they'll go with a small bit of pepper in writing all this noises in very very small points and they'll keep in the packet and after seeing what case that comes they will throw all the other case only have that which case they get a long case like thyroid or breast so it's not needed you have to just remember the basic outline you the examiners will not fail you for missing one or two points which you are which you might have not asked in the exam they will not fail you please understand it so he's still taking of thyroid gland we are going to examine this lady now
24:54 45 years female with the left side thyroid swelling is coming to you so this lady Mrs Kamala 45 years female with the left side solitary nodule thyroid comes to you this is a lady with the thyroid swelling you are seeing here that is a thyroid swelling left side solitary nodule you can see that is moving with the deputation so we are going to examine about this lady now one by one so you should ask the basic history name age six occupation residence and please don't forget carcinoma as well as thyrotoxicosis both are common in females so both cases are common in females carcinoma as well as thyrotoxicosis both are common in females so now let me tell you what all the headings you should know
25:40 for asking history in thyroid so history of presenting illness so the first TC the patient will come to you with this will be with the swelling swelling and pain this will be the two history for a thyroid filling only swelling and pain so swelling when the patient comes to you the swelling you should ask about the duration of the thyroid swelling so how long is it present for three months or one year or ten years like that you should ask and plus the point duration number two when you tell about duration after that you should tell about uh inside a handset how does it start it started as a small swelling and gradually increased in size or suddenly she noted as a big swelling on one day like that answer progress whether it is
26:26 slowly progressing or fastly progress for the past few months so onset progress so duration onset progress of the swelling you should ask then you should ask about whether there is any Associated pain so this is the first heading of History you should ask so I'm telling you one by one the history headings if you know the history heading you can ask all the inside questions easily so Associated pain now let me tell you what are all the history should be asked so let me uh start with duration of the swelling tell me which all thyroid so links will have short duration short duration of thyroid enlargement is seen with cancer and with
27:12 thyroiditis inflammation and Cancers will have short duration long duration is seen with Collide guide us patient has a long duration of swelling will be usually a Collide guider so Collide guiders will have due diodine deficiency guider will be there for long duration of patients will have colloid data so duration will help you to come to one clue and progress which one will progress very rapidly progress with very rapidly Progressive so when the swelling is rapidly progressing there are more chances that it can be a cancer or it can be a thyrotoxicosis thyrotoxicosis like Graves can be
27:58 progressing very very fast growing thyroid swelling okay so Insidious onset or rapid onset so rapid onset and enlargement is seen with Graves disease so Graves disease and most important the examiners will stop you to ask what are all the painful thyroid swellings you know so like that when you are presenting one history the examiners can interfere and ask you what will you think about a painful swelling what do you think about the painless feeling like that they will be asking you can you tell me what are all the painful thyroid swellings most important I'll tell you most of the thyroid Shillings when they come to hospital will be painless or the word postgraduate will be doing
28:46 an fnac so suppose post F1 AC the patient might have pain please remember post fnac pain may be there patient will tell her before coming to hospital I never had a pain after this fnac was done I am having severe pain this history is very important most of the time your word cases will tell this is you should notice that means what fnac done might be because of that trauma patient is having pain so number one number two what other cause of pain thyroiditis will have pain thyroiditis will have pain then very important cancers infiltrating the nerves otherwise you don't have pain only when the cancer infiltrates the nerve they will have pain otherwise they won't have pain yes so anaplastic cancer
29:32 most of the malignant cancers you can see they will have there will be a short short duration so cancers especially another plastic cancer is very short duration okay the only cancer which will have a long duration is follicular cancer because it arises from a colloid Guyton so follicular cancer arises from word from a colloid gutter so it will be there for a long period and after a long period suddenly deserving a rapid growth that is what CNN follicular cancer so these are all very important things if you read about each disease you'll be able to answer these points so post fnac thyroiditis cancer so which thyroid is allow no pain can you tell me thyroiditis will have pain which thyroiditis will have no pain so riddles riddles thyroiditis is a
30:18 painless thyroid swelling so real Pharisees is painless except riddles thyroidism so all other thyroid is Decor wine all the relatives will have pain except real side so the first history category is history of present illness so present please remember when you tell about present illness patient will come to you either with a swelling or with the pain only they will come to you with the swelling or with the pain only the patients will come to hospital okay second category of History so please remember the first category of history is history of main complaints major complaints a patient has come to you now history of pressure effects sorry so coming to the second history history related to pressure effects what are all the history related to pressure by the
31:04 thyroid gland so please remember thyroid can when it becomes very big it can compress what are the suggest you can compress it can compress esophagus it can compress trachea it can compress yes or you can compress common carotid artery it can compress and cause recurrent laryngeal nerve infiltration or damage it can cause so esophageal compression will cause dysphagia history of dysphagia dyspnea
31:55 common carotid artery compression can cause syncopal attacks recurrent laryngeal nerve compression can cause hoarseness of voice so what are all the structures around the neck it can cause compression please don't forget it these are the commonly compressed structures around the neck so the causes of compression can be larynx cast compression so tracheal compression actually it's a tracheal compression esophageal compression recurrent laryngeal now carotid vessels very rarely this is seen compression of cervical sympathetic chain causing harmless syndrome these are all not so common don't commit and get into trouble so rarely it can cause hardness syndrome ptosis meiosis and hydrosis due to compression of cervical sympathetic
32:41 chain so next we have to ask about history of talk history suggestive of toxic features history suggestive of toxic features you should ask now next important history is about the toxicos now we are going to ask about the physiology dysfunction of them so one by one first you should ask about history of present illness second about the pressure effects third about the toxic features can you tell me what are all the toxic features patients will have weight loss weight loss in spite of increased appetite patient is eating very well very well excessively easy thing but there is a weight loss then patient has diarrhea patient deserving diarrhea weight loss
33:26 weight loss diarrhea then patient is having very important mannerasia so in case of toxicosis there will be hypomenorrhea decreased a cycle period okay hypomenorrhea heat intolerance okay palpitations and Tremors patients will tell I'm having palpitations and traumas and sleeplessness due to sympathetic overactivity Sleepless so you can ask all these points in history so the increased appetite diarrhea weight loss High pulmonary heat intolerance palpitation Tremors all these things are are given in history very rarely patients will be
34:11 telling eyeball protrusion it is not usually told in history some of the people surrounding the patient would have told your eyeballs are protruding so some of the time that might be told by the patient but usually patients will not tell about exact almost when you ask you see that she might tell that patients attend us some of the attenders are some of our husband husband or some other people told that you are having a protrusion of eyeball so that is very rarely asked you see so the third history is about the toxicosis excess sweating weight loss heat intolerance diarrhea or hypo or a manoria this is the third histies and coming to the fourth history that is on hypothyroidism so hypothyroidism is still immediately you will tell physiology question so history of hypothyroidism
34:57 so you can see everywhere we are discussing the basics like Anatomy physiology pathology everything will be coming in next exam if there is going to be a next exam all these questions will be the applied basic science you will be asking your exam and billion law gives extraordinary outline of all the basics you need not open any other basic science book if you see Bailey you can answer most of the question hypothyroidism will have weight gain hair loss okay hair loss loss of appetite in spite of loss of appetite patients will have weight gain due to mucough polysaccharide depositions in most of the places so we gain hair loss loss of appetite constipation
35:42 lethargy so patient will be very much lethargic so all these are very important features of hypothyroidism very important cold intolerance they cannot withstand even a normal room temperature they will feel very cold so cold intolerance all these are features of hypothyroidism so please remember what are all the four these trees coming to the history of hypothyroidism then the last is still related to cancer history related to cancers what are all the features to have patient having a cancer so history number one there is no other swelling please remember if there is a cancer patient will tell some mother swelling also apart from thyroid swelling patient will have a swollen in the scalp Bone Image patient will have a swelling in the neck itself
36:28 nodal feeling like that multiple other swellings will be seen so presence of no other swelling history of cancer will have presence of no other swelling so then what other features will be very important for history of cancer so no other swellings is another history and please don't forget cancers will have history of weight loss again history of weight loss will be asked history of bony swellings anywhere in the body you should ask history of hemoptysis history of hemoptysis due to lung meds so lung meds are very common with papillary cancer so if there is a lung participation may have hemoptysis history of abdominal swelling which thyroid cancer produces liver mats can you tell me
37:16 abdominal swelling is due to liver meds which thyroid cancer can is commonly produces liver meds see most common site of distant myths of various cancers can you tell me the thyroid cancer discernments papillary cancer where is the distant meds it is to lungs follicular cancer varies the distant mates molecular cancer the distant matches to skull pulsatile skull secondaries which cancer produces liver secondaries my question is which cancer produces liver secondaries from anybody yes so many of you are attending the session can you tell somebody you can tell what where is the common sight of
38:01 liver secondary liver secondary is most common in medullary cancer of thyroid very important liver secondaries can produce liver secondaries can produce abdominal swelling so that is the most important point you should not forget so this is about the malignancy you should ask about bone pain dyspnea weight loss jaundice when there is a liver meds very rarely they may even have jaundice so these are the basic history so what are all the histories you should ask in a thyroid swelling so in a history of thyroid swelling first important is history of present illness second important history is history about there pressure effects of the thyroid swelling number three history of toxicosis Number Four history of hypothyroidism
38:48 number five history of cancer so now do you think you need a small bit or notes to carry home into the carry into the examination all not needed you just remember only five points you should remember in history taking off thyroid swelling so please remember what are all the five questions should be asked in history of thyroid so then comes past history so past history there is nothing special you should know the past history of history of any irradiation are like diabetes hypertension ischemic heart disease all those things are routinely asked and past history of irradiation why should I ask if there is a past history of irradiation the patients can now develop capillary cancer that is why I am asking about the
39:36 past history of papillary cancer so very important so any past history of irradiation is a very important question for your exams so any pass history of irradiation or past history of any drugs there are many drugs which are gaetogenic which you might be reading in Pharmacology so please remember drugs history our patient is having any menstrual history the diet history family history of any thyroid problem can you tell me which are all thyroid problem which can run in families family history of thyroid swelling so family history that is a family history of iodine deficiency please remember in one family iodine deficiency can cause greater to all the people in the family because entire family is not taking proper iodine intake so iodine
40:22 deficiency among the all the family members number one so iodine deficiency guider number one number two medullary cancer of thyroid runs in families due to Red oncogene mutation red toncogene mutation causes medullary cancer thyroid which is running in family so family history of medullary cancer can also happen so family history is also very important you should ask about family because families they have similar swelling is seen in goiters and family history of medullary cancer is seen and ret oncogene mutation so please don't forget these points related to history taking these are the essential points in history taking you should not forget so KCC as of now we have let us assume this lady has come to you with a
41:08 left side thyroid not associated with pain please remember I'm just concising the history so left side solitary nodule of thyroid 40 years female come to me with the left side solid in ideal of thyroid solitary nodule not associate we should not tell it as thyroid here if we send it to the left side solitary nodule not associated with pain no pressure effects so she is having history of constipation and in hypothyroidism that is history of menorrhagia and no evidence of any bone pain or loss of wheat no evidence of bone pain or any loss of heat this is the history or
41:55 weight loss so this patient is now having pure from the history what can I come to you conclusion this I can come to conclusion solitary nodule of thyroid with hypothyroid features this is what I can conclude a conclusion so from the history taking now I am going to confirm it by examination of the thyroid so very important in general examination I am not going into the general examination let me go to the local examination of thyroid swelling local examination of thyroid swelling so very important please remember local examination of thyroid swelling on inspection so inspection of thyroid filling what are the findings you see on inspection of the parietaling on inspection of the thyroid swelling you should note that is
42:41 a swelling in front of the neck you should tell about sight size shape surface of the swelling very simple basic Point side size shape surface so if in this case on the left side of the thyroid gland area there is a 3 into 3 centimeter solitary nodule globular shape with a smooth surface is seen with a smooth surface is seen and nose car or sinus no SCAR or sinus no dilated veins seen so these are all points you should never make up you should tell very fluently just by seeing the swelling you should tell there is a swelling like this having a smooth surface all those
43:27 things you should tell immediately So based on the swelling it is butterfly or this patient our patient is having only a left side swelling so it is a globular shape skin over swelling is normal plane of the swelling this is very important question very commonly the students will be asked so many questions from the plane of swelling what is the plane of swelling so plane of the swelling so if to know the plane of swelling I should put the muscles in the neck into contraction this is a classical Viva question so where is the thyroid gland located it is deep to trap muscles in the neck and it is deep to
44:12 cervical pre-trachial fascia how to test this why I am saying it is a deep two strap muscles can you tell me what test I will do to know the swelling is deep two strap muscles number one keep the hand like this and ask the patient to flex the chin you palpate the swelling the swelling becomes less prominent on putting the strap muscles into contraction it becomes less prominent how to know it is deep to steep pre-trachial fascia so deep to strap muscle because on putting the strap muscles into contraction it becomes least prominent and deep to breed tracheal fascia because if I extend the neck I stretch the fascia the muscles and other soft tissues will get compressed and the
44:58 thyroid becomes more prominent so more prominent on extension of the neck so very simple testing to test put the Deep muscles into contraction and Stitch the neck so two test will show you whether it is where it is the plane of the swelling is deep to the strap muscles and deep to pre-trachial fascia on deep two strap muscle because putting the muscle into contraction it becomes less prominent and on stretching the fascia it becomes more prominent that is the plane of swelling and it moves with the degradation don't forget this point so this immediately The Examiner will ask you why it moves with regulation you should expect this question and you
45:43 should be careful and ready to answer it is because of the pre-trachial engulfment of the gland which is attached to the hyoid bone it moves with declutation it does not move with so does not move with protrusion of tongue this is a very important differential diagnosis in the midline swellings so not move with protrusion of tongue if it is in the midline you should ask this history definitely but a little near mid lane also you can ask so I am asking not most of the protrusion because only thyroglossal cyst will move with protrusion thyroglossal cyst is a smarter question for your exams so please remember thyroglossal cyst will move with protrusion of trunk it will not move with the prototion or moves with the protrusion you should not forget this basic history so I am going
46:29 on inspection so inspection what do you mean by trial sign what is mean by trial sign on inspection some important inspective findings examiners will ask you so when you ask when you examine the neck if the sternocleidomasted on one side is prominent what does it mean prominent sternocleidomastide muscle means there is a deviation of trachea that is deviation of trachea please don't forget this there is a deviation of trachea will have prominent substance muscle that is known as trial sign please don't forget what is trial sign so deviation of trachea will cause prominence of sternoq domestic if there
47:16 is a one side swelling it will cause deviation so these are all the inspectory findings you should not forget number PSI size size shape surface skin over plane of the swelling pulsations any pulsation scene it is usually seen in Graves disease in Graves this is you can see prominent vessels causing pulsation movement with regulation movement with protrusion law a very very important Point look for the lower border of the swelling so can you tell me why should I look for the lower border of the swelling anybody why should I look for the lower border of the swelling if lower border of the swelling is visible I'm happy if lower border is not visible for example this is a lawyer border not visible what should I do immediately if there is no
48:03 lawyer board or visible immediately I should do one test what is it the patient's thyroid lower border is not visible means it can extend into the retrostanam and can compress the very important point it can compress the SVC Superior when I cover it can go and compress and it can cause it can cause a syndrome known as SVC compression syndrome so it can extend inside and it can cause SVC so such very good C that is correct to rule out retro tunnel extension only we should see for the lower body lower border is not visible immediately ask the patient to do this test this test is known as Pemberton sign very important
48:49 sign Pemberton sign should be done immediately remembered and sign is done to bring out this SVC syndrome any patients will already have dilated rings if I do like this it will still compress more the SVC and patients will develop dilated veins dilated veins will happen in the face the patients will develop dilated veins or the face and there will be patients May develop congestion of the eyes all these things will happen if there is Pember 10 sign positive so very rare syndrome if you do this Pemberton sign the dilated veins will cause dilated veins and the congestion of ice means what retro external extension has caused SVC compression so these are the important questions from inspection what is PC loss test
49:37 so PC loss test is done for short-necked individuals not for all people only for short neck individuals very short neck individuals we ask them to clasp the hand behind the neck and extend the neck like this to see the thyroid prominently so only for short neck individuals we do this PC laws test all the named tests will be asked by the examiners to demonstrate so this is a trial sign you can see if there is a prominence of Stena glutamastoid muscle it is said to be trial sign it is known as trial sign okay and this is the silos method of examination patient is extending by clasping the hand behind so this girl you can see she's having a thyroid swilling the lower border is not visible so what I am going to do I am going to ask her to do Pember 10 sign you can see
50:24 the eye is becoming red and dilated veins will happen after some time so this is known as Pember 10 sign please don't forget this is you can see a case of long-standing goiter with a retrospinal extension causing dilated veins you are seeing in this case so now coming next to the palpation of the thyroid gland so inspection completed next we are going to the palpation of thyroid gland penetration of thyroid gland is always done from front or back always done from
51:10 back of the patient not from the front please remember if you if an examiner asks you to go and palpate the thyroid swelling if you go like this and examine immediately naturally voluntarily the patient will put the neck into contraction as if you are going to strangulate the patient therefore you cannot palpate the findings properly always examine from back with the neck slightly fluxed like this with the neck flux set position you examine from back so not the side size shape surface everything is now again confirmed and extend Here Comes an extra point in extend extend you should tell there is a three three into three
51:57 centimeter thyroid swelling extent is it is seen 2 centimeter below the hyoid bone and above the external large it is three centimeter from the scanner lot so you have to tell some bony Landmark so medial to sternocleidomasti this is 10 acute a mastoid muscle so medial to steno glutamastite two centimeter below Hyatt bone three centimeter above the tunnel Notch I can palpate the swelling which is 3 into 3 centimeter exactly you should use tape until the thyroid swelling here you have to use tape and measure so very important because in palpation extent is very important for us we have to know the extent of swelling where does it extend etcetera so in palpation again I will confirm
52:43 movement with regulation so movement with regulation is again confirmed by holding the thyroid swelling it will move with the degradation so very important point now in the palpation of the thyroid gland very important is we have to calculate for carotid artery carotid artery palpation is now very important so it is palpated at the level of size and tubercle carotid tubercle known as Chase and tubercle against the Bony vertebrae you have to palpate it so when the examiner asks you to palpate carotid artery please remember you should only palpate unilaterally don't palpate bilaterally if you palpate bilaterally I have seen examiner asking
53:28 the student to go and palpate the Carotid artery both the carbidities if the student is going and palpating simultaneously as examiners will fail the final student because if you palpate both the Carotid artery simultaneously patient will develop syncopal attacks so you should only do unilaterally if you do bilateral palpation you are failed in the exam be careful with that so in a carotid artery is usually palpated against the chains tubercle of the vertebrae and the transverse process of the vertebra you can palpate in case of benign swellings it can can be pushed laterally pushed laterally in a benign swellings in which case it is not palpable carotid artery not palpable is a feature known
54:14 as what sign the sign is known as Berry sign it is the feature of cancer in the thyroid when there is a cancer in the thyroid the Carotid artery is not palpated the Carotid artery is not palpated if there is a cancer the cancer will infiltrate it and it will not be palpable very important point you should not forget this so cancer is carotid artery not palpable so now you should also do a lateral compression caucus see every name test will come in palpation Berry sign test so what is carcass test if I give a lateral compression on the thyroid gland patient will develop Strider if there is a tracheal compression patients will develop Strider on lateral compression
54:59 of the thyroid gland patients May develop Strider so please remember carcass test patients will develop Strider so what are all the other tests which should be done in palpation very very important laggies test and krills test so the two tests you will do from front of the patient so when the examiner asks you go and do lagis test go and do coils test you should automatically come to the front of the patient you should not do it from behind so what is lag is test see the video of laggies test so this is how you should always palpate from behind the patient by putting the patient in cycling neck fluxed position please don't forget so I am now showing ligase test so now you can see push the thyroid gland with three fingers and palpate with the remaining three fingers
55:45 this is coming from front push the thyroid gland with three fingers palpate with the other three fingers known as laggies test so now you can see three finger paste Crane's test for doubtful small nodules keep the thumb like this and ask the patient to swallow see this is crazy you can see this question came as a video based question in page entrance exams so you should be thorough the thumb kept on the thyroid trolling you can see the patient on swallowing you can palpate them surface of the swelling very important consistency Mobility palpate the lower body do for pressure effects and palpate fertile this all done in real patient so
56:33 regarding the consistency of thyroid swelling soft consistency is seen in Graves disease okay firm consistency is seen in Collide guide us hard consistency is seen and riddles thyroiditis and then cancer and in cancer you will have a hard consistency in cradle thyroidism and in cancer so please don't forget to palpate the lower border because if you palpate and inspect the lower butter no further test is needed so palpation of thyroid proy thyroid can be heard in the superior outer part of paragland superior pole of thyroid
57:18 gland you can hear the Brewing on auscultation that same Brewing can be palpated as thrill on palpation thyroid Superior thyroid artery Brewery this is due to Superior artery Brewery commonly seen in Graves disease not in other cases it is seen only in grapes this is you will see the rui okay please don't forget Superior artery Graves this is Brewery is seen so what are all the name latest I told you carcass test for tracheal compression carotid artery you should look for any pulsations are filled sympathetic trunk if it is compressed you can see doses of the dice meiosis and and hydrosis can be
58:04 noted but these are very very rare situations ptosis meiosis and hydrosis are very rare situations on palpation so Berry sign malignant thyroid engulfs the Carotid sheath hence pulsation is not filled as Berry sign so please don't forget these points so then coming to percussion percussion over the manibrium sterni to look for retrospinal extension and primary toxicosis you can hear the and never ever forget to palpate for the remaining nodes in the neck so what are the uh points in palpation you should be on you will be asked in the examination to demand status in 12 patient the examiners may ask you to demonstrate carcass test demonstrate caucus test number one number two demonstrate Berry
58:52 sign number three demonstrate lie his test number four demonstrate trials test lemon State crimes test told caucus test battery sign lag is test price test these tests will be asked by the examiners to demonstrate okay please don't forget all these points in palpation and these are essential points you should know how to show this test in clinical why were because examiners old examiners will expect you to demonstrate all these tests so they will stay tuned to demonstrate all these tests in the exam so this is clinical examination of thyroid what are the other things you should not miss I am going to ask you like an McQ you should tell me now other
59:38 things examined in thyroid are right from head to food let us start one by one first thing you should examine is I signs so right from other things to be examined I am coming from head to foot so in eye science first thing is I signs I signs that are exact almost you should look for any exact almost what is exophthalmosis so exactal Moses is confirmed by nav zigal's test what is nav zigas test so many named tests will come you should be thorough with all the names it is you should make the patient sit in a chair like this and you examine the patient from Supra ciliary Ridge like this so examination via
1:00:25 if I see from above I can see the protruding eyeball will be noted that is known as nav zigger's test so nav ziga's test is a test to confirm there is exact almost the eyeball is protruding if I am seeing from above what is differs test first so many named test so defaults just says nothing but in childhood days you used to play with the evolution of eyelid by averting the eyelid you'll threaten your small babies so that is known as aversion of eyelid upper eyelid a version of eyelid is possible or not possible in Graves is not possible in graves because of Muller's muscles person a version of eyelid is not possible because of moonla's muscles
1:01:12 spasm you cannot avert the upper eyelid that is very important default so please remember nav zigal's test gifats test NAB ziggest examination Jeffers Justice aversion of eyelid that is muscle spasm so you cannot ever dip in which condition you can ever nav ziggers test positive but apparently not avertible is nothing but proptosis so what is the difference between proptosis and exact almost very basic question examples is a thyroid pathology okay thyroid pure thyroid pathology causing enlargement of eyeball or protrusion of eyeball due to spasm due to mullah's muscle spasm and retro
1:01:59 orbital mucopolysaccharide deposition causes exact almost droptosis is not a thyroid problem it is a pathology behind the eyeball pathology behind eyeballs some pathology like retro orbital tumor something retro orbital hematoma that will cause protrusion of eyeball it is usually unilateral proptosis is unilateral except almost this is bilateral always see very important you should know how to differentiate exact almost and proptosis exopthalmosis Asia thyroid pathology proctosis is a retro orbital pathology so I signs you should look for high signs if there is exact almost immediately you should do all the
1:02:44 eye signs like one graph is sign so when you read itself you should read like one graphy lid lag sign okay Java fries jar of rice absent wrinkle sign s absent wrinkle sign see one graph is little like sine Joffrey is absent wrinkle sign Mobius absent convergence sign apps and converge and sign number four one graph is lidlaxine job price absent wrinkle sign Mobius absent conversion sign Dal Rim tea
1:03:31 dial dreamtase lid retraction sign number five still walks starring Loop sign so these signs you should be able to demonstrate the examiner will ask you come on demonstrate this one graph e sign keep a pin in front of the patient and ask the patient to follow the pen continuously like this do it multiple times when you are doing multiple times like this the patient will not follow the pen and the lids will lag that is known as one graph is sign one graphic sign fix the head like this and ask the patient to see the ceiling if you are seeing your eye you will do wrinkling of the head here forehead here whereas these people have the eyeballs protruding out the eyeballs will directly see the ceiling so absent
1:04:18 wrinkle sign is job rise and Mobius sign you keep a pin like this and ask the patient to converge your eyeball so they are unable to converge the eyeball because of the okay so Dal rimty sinus the upper lid is retracted so you can see the upper sclera upper sclera visible like this patient will be starring like this tiring look sign so these are the five I sign so from head to foot you can examine all others other things to be examined in a thyroid see in a thyroid exam case if you get a thyroid exam case you can get medal at the end of presentation itself that much points are
1:05:03 there in thyroid examination itself we have so many points so I signs you should examine you should tell about exact almost nav ziggers test differs test so one graph is lid lag job price absent wrinkle Mobius apps and convergence dial rimpses lit retraction and still works starring look sign all are essential signs for your exam please don't forget these signs asked in the exam for you in I sign second then from Health to food I am coming down from head to food I'm coming down look for loss of eyebrows eyebrows are lost okay number two number three coming to the mouth in the mouth you should ask the patient to keep the tongue inside don't ask them
1:05:49 to protrude if you protrude like this even if you protrude you will have tremors small Tremors can happen normally therefore ask them to open the mouth keeping the tongue in the mouth itself and look for fasciculations so this is from Hutchinson thus mentions as protrusion of tongue so achinson mentions you should keep that tongue inside the mouth for Fascinations so if you protrude out naturally everyone will have fasciculations please remember on the tongue at the anterior two third to posterior one third Junction if that is the swelling what is this an examination of the oral cavity on the anterior two third and posterior one third tongue there is a swelling like this what can it be it can be a undescended thyroid
1:06:37 known as lingual thyroid so you should look for most common site of ectopic thyroid that is lingual thyroid you should examine in the oral cavity okay then comes the fourth important thing is examine for node in the neck nodes in the neck so I hope you know the levels of notes there are seven levels of neck nodes you have to examine step by step you just don't go and examine here and there in the neck you have to go systematically each level of nodes you should examine and you should be able to find out some notes in some group so please remember level one node is submental node and submandibular node submental submandibular is level one level two is upper jugular level three
1:07:24 is Middle Jeweler level four is lower jugular sub mental node and submandibular is one two three four upper middle lower but most importantly you should not forget five is posterior group of nodes five is first in a group of nodes for thyroid the most important node is six laryngeal node what is other name of P laryngeal node it is known as delphic nodes and pre-trachial node is this and level 7 is upper media channel node upper mediation so what are all the nodes in the neck so one two three four
1:08:10 five six seven nodes you can see you have to palpate for all the seven group of nodes so go and examine each and every individual node you should very slowly examine don't miss any notes then coming to five examination of hand on examination of hand ask the patient outstrets the hand and keep the finger stretched like this keep a piece of paper on the hand you can see fine drummers fine drummers are seen fine dramas are seen and in CNN thyroid toxicosis and acrobati acrobati is a digital resorption seen in thyroid oxycosis patients resorption of digits
1:08:55 disruption of digits is seen in acrobati then you come down you can see pre-tbl mixed edema in the leg three tibial mixer demise another mucopolysaccharide deposition in front of tibia so though it is known as mixer demo it is a feature of thyroid oxycosis it's a misnomer people named it wrongly as mixed edemide is a feature of thyroid oxygos mixed edema is a feature of thyrotoxycosystem so all these findings you should examine one by one so look for a Tremors eye signs pulse rate heart and moist pumps when you give shaken to these people toxic patients will have heart and very moisty forms full of sweating in the hand so eye signs don't forget to mention all these eyes different
1:09:40 still works one graphy job fry Dal remedy Mobius and this is not important gel Linux is pigmentation this is not important so remember this High signs I told you so you can see the visible upper Spira known as dial Rim tea it is known as dial Rim T sign okay so this is still what starring look sign Del the dull remedies visible upper sclera also known as lead retraction sign lid retraction causes visible opposite of Dal Rim T sign so Joff rice sinus absence of wrinkling of forehead when you ask them to see the ceiling there is no wrinkling very important sign so in this which is a severe exact almost mild examples first three signs
1:10:26 still works one graph is dull remedies severe is Mobius please remember it is due to intraorbital accumulation plus paralysis of muscles in mild it is only sympathetic over activity moderate is due to Retro orbital tissue accumulation and severe is due to paralysis of muscle so please don't forget from the eye signs itself I can say whether it is mild moderate or severe severe is a PG question so severe is a PG question Mobius is severe example almost which is due to intraorbital accumulation plus paralysis of the muscles patient is having inability to converge the eyeball so due to Retro orbital tissue accumulation is drop rice mild is only sympathetic power activity is mild still
1:11:11 works one graph is dull REM T sign this is grading of exact almost so this is a malignant case of exact almost patients has keratitis epiphora chemosis orbital Hemorrhage these patients need emergency we have to give steroids and do lateral tarsography for malignant except almost cases and other systems you should examine especially secondary toxicosis they may have cardiac failure features eye science will be very rare in secondary toxicosis there will be no Tremor no exact almost in segmentary toxicose I hope you know what this secondary toxicosis let me give you a brief differentiation between primary toxicosis please don't forget this is a very basic second mbbs point and the secondary
1:11:57 toxicosis you should never have a confusion in this primary toxicosis is seen in Graves basic point Graves disease the thyroid swelling happens along with toxic features so thyroid enlarges along with toxic features due to long-acting thyroid stimulating antibodies so it is an autoimmune disease long-acting thyroid stimulating antibodies causes the enlargement of thyroid gland plus toxic features together it causes enlargement of thyroid gland plus toxic features
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