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SU22.1-6 | Thyroid and Parathyroid Surgery — Assignment
CLINICAL SCENARIO
A 38-year-old woman is referred to the surgical clinic with a lump in the front of her neck that she noticed three months ago. It is painless and has grown slowly. On examination there is a single 2.5 cm firm nodule in the right thyroid lobe that moves upwards on swallowing; the rest of the gland is impalpable. She has no symptoms of over- or under-activity of the thyroid, no hoarseness, and no palpable cervical lymph nodes. Initial blood tests show a normal serum TSH.
Instructions
Take this patient through a complete, reasoned work-up and management plan for a solitary thyroid nodule, applying the principles you studied: confirming the swelling is thyroid in origin, the correct investigation pathway driven by the TSH, the role of FNAC and the Bethesda system, the type-specific behaviour of thyroid cancers, and the principles and complications of thyroid surgery. Justify each decision rather than listing facts, and write in structured clinical prose.
Length: 900–1200 words
What to Submit
1. Clinical assessment and examination
Describe how you would confirm that the swelling arises from the thyroid and how you would examine and document it. State the differential diagnosis of a solitary thyroid nodule and the features you would specifically seek that raise suspicion of malignancy.
Guidance: Use the 'moves on swallowing' sign (pretracheal fascia) and contrast with the thyroglossal cyst. Include growth rate, pressure/voice symptoms, thyroid status, age extremes, irradiation history, family history, fixity and nodes.
2. Investigation pathway
Set out the investigation sequence for this nodule, explaining how the serum TSH directs the next step, and why. Describe the role of ultrasound and FNAC and how the Bethesda system is used to guide management.
Guidance: Normal/raised TSH → ultrasound + FNAC; suppressed TSH → radionuclide scan first. Explain why a normal TSH does not reassure, and what FNAC can and cannot tell you (e.g. follicular lesions).
3. Thyroid cancer — four diseases
Explain why thyroid cancer is best understood as four distinct diseases. For papillary, follicular, medullary and anaplastic carcinoma, summarise the cell of origin, characteristic behaviour/spread and one key diagnostic feature.
Guidance: Papillary (follicular cells, lymphatic spread, psammoma bodies); follicular (follicular cells, haematogenous, needs histology); medullary (C cells, calcitonin, MEN-2/RET); anaplastic (undifferentiated, elderly, aggressive).
4. Principles of surgical management and complications
Outline how the management of this nodule would proceed depending on the FNAC result, and the principles of thyroid surgery. Describe the two most important specific complications of thyroidectomy and how you would counsel the patient about them.
Guidance: Relate surgical extent to diagnosis; cover recurrent laryngeal nerve injury (voice) and hypoparathyroidism/hypocalcaemia (Chvostek/Trousseau, perioral and digital paraesthesiae). Mention the external laryngeal nerve at the superior pole.
Grading Rubric — Solitary Thyroid Nodule Case — 20 points
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Clinical assessment, examination and differential | 5 pts | Correctly confirms thyroid origin, documents a structured examination, gives an accurate differential and lists the malignancy red flags. |
| TSH-directed investigation pathway and FNAC/Bethesda | 6 pts | Accurately uses TSH to direct the pathway, justifies ultrasound and FNAC, and correctly explains the Bethesda system and the limits of FNAC. |
| Type-specific understanding of thyroid cancers | 5 pts | Clearly distinguishes all four cancers by cell of origin, behaviour/spread and a key diagnostic feature. |
| Surgical principles, complications and writing quality | 4 pts | Relates surgical extent to diagnosis, correctly describes recurrent laryngeal nerve injury and hypoparathyroidism, counsels appropriately, and writes clearly. |