ROJoson PEP Talk: HARD Thyroid Nodule - BENIGN Pala

ROJoson PEP Talk: HARD Thyroid Nodule - BENIGN Pala

1. September 28, 2024 1400H - 1500H Via Zoom Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management.

2. September 28, 2024 1400H - 1500H Via Zoom Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. Welcome all! MUTE yourself but always show your video picture. Sign in your name, FB account, or email address in the Chat Box! Include names of companions attending. Use the Chat Box to ask questions and make comments while the PEP TALK is on. There will be group pictures at start and end of PEP TALK – show your face in video.

3. t Reminder after the PEP Talk: Take the Online Learning cum Evaluation Test Exercise (OLETE) for mastery of learning and have a perfect score to get a Certificate. Link is in Chat Box.

4. Reminder: 25 OLETE Certificates = 1 Voucher for ROJoson Medical Consultation either Face-to-Face or Telemedical.

5. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. ROJOSON’S REQUEST: FEEDBACK TO THIS PEP TALK! Pls. type in your feedback in the chat box during the open forum and before we adjourn! Thank you!

6. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. LET’S NOW HAVE A GROUP PICTURE TAKING BEFORE WE START PEP TALK PROPER IN 2 MINUTES! Pls. turn on your video! Show your face!

7. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. ROJoson PEP Talk I have a Patient Empowerment Program in which I like to empower the lay people or patients to take control in the management of their health.

8. I started the PEP Talk on May 15, 2021 during the COVID19 Pandemic. There are 3 courses in the PEP Talk. I completed the Core Course on October 9, 2021.

9. From October 23, 2021 onwards, I have been tackling Health Disorder and Health Issue Courses. May 18, 2024 marks the start of YEAR 4 of ROJoson PEP Talk. How long the PEP Talk will last will depend on our enthusiasm , discipline and perseverance .

10. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. My PEP TALK today is entitled: Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

11. Contents What is a medical anecdotal report or MAR? Narration Insight / Reflection MAR Title: HARD Thyroid Nodule – Benign Pala Reporter : Dr. Reynaldo O. Joson Date of Medical Observation: 2024 Disclaimer: ROJoson PEP Talk contains ROJoson’s Thoughts, Perceptions, Opinions and Recommendations (TPORs) culled from experiences of ROJoson and writings of other health professionals . Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

12. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR : HARD Thyroid Nodule – Benign Pala GIST of MAR A 55-year-old Filipino female presented with a thyroid nodule of 2 to 3 years in duration. Because physical examination revealed a HARD solid thyroid nodule on the right thyroid, a thyroid cancer was suspected. Needle aspiration was done which yielded 5 cc of colloid fluid followed by almost complete disappearance of the thyroid nodule. The HARD thyroid nodule was BENIGN pala . The HARD thyroid nodule turned out to be BENIGN after all.

13. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Some reflection and learning points and issues: What are the alert signs for thyroid cancer? What were the alert signs for thyroid cancer present in this patient? Am I justified to suspect thyroid cancer present in this patient? Can my palpation and interpretation be wrong? In retrospect (or looking back), is there really something wrong with with my palpation and interpretation of HARD SOLID thyroid nodule? In retrospect (or looking back), can I be faulted in placing Thyroid Cancer as my primary clinical diagnosis? Are all HARD thyroid nodules cancerous? What are benign thyroid disorders that can present as HARD thyroid nodules? ROJoson’s tips on management of similar situation

14. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala What is a medical anecdotal report or MAR? MAR is operationally defined by ROJoson as a brief written report on an actual medical event that involves an actual patient. The medical observation must have an impact on the reporter in terms of insight gained and which the reporter thinks is worth sharing with other people, usually for learning purpose. The MAR will have 2 parts: Narration Insight or Reflection

15. NARRATION I had a patient, MO, 55 year-old female who on July 16, 2024, consulted for a neck mass ( bukol sa leeg ) noted 2 to 3 years ago. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

16. NARRATION On physical exam, there was a HARD thyroid nodule, solid, 3-3.5 cm, on the right. There were no neck nodes. Pulse rate was 68 beats per min. My primary diagnosis: Thyroid cancer My secondary diagnosis: Benign thyroid nodule Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Bases for suspecting thyroid cancer – hard solid thyroid nodule

17. NARRATION I discussed the options of what to do next: Ultrasound of the thyroid gland Needle aspiration +/- biopsy She opted for a needle aspiration +/- biopsy right after the clinical evaluation. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

18. NARRATION Needle aspiration was done which yielded 5 cc of dark brown colloid fluid. This was followed by an almost complete disappearance of mass. My post needle aspiration diagnosis became: Colloid nodule, right with 90% degree of certainty Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

19. NARRATION Needle aspiration was done which yielded 5 cc of dark brown colloid fluid. This was followed by an almost complete disappearance of mass. My post needle aspiration diagnosis became: Colloid nodule, right with 90% degree of certainty Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

20. NARRATION With my post needle aspiration diagnosis being: Colloid nodule, right with 90% degree of certainty I recommended medical suppressive therapy with levothyroxine, initially 100mcg / day for one week and then 200mcg / day thereafter until next clinic visit. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

21. NARRATION I recommended ultrasound of the thyroid for baseline monitoring purpose. I also recommended self-monitoring the thyroid nodule and the neck. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

22. NARRATION Two weeks after, she came for follow-up visit. The right thyroid nodule has decreased in size from 3-3.5 cm to about 2.5 cm with 200 mcg of levothyroxine. Ultrasound done August 1, 2024 showed predominantly cystic nodule (4 cm). Note: she was aspirated on July 16, 2024. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

23. NARRATION I advised continuance of levothyroxine 200 mcg / day with follow-up visit after one month. I also advised continuous self-monitoring of the neck. A medical suppressive therapy is being done for this patient. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

24. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR : HARD Thyroid Nodule – Benign Pala GIST of MAR A 55-year-old Filipino female presented with a thyroid nodule of 2 to 3 years in duration. Because physical examination revealed a HARD solid thyroid nodule on the right thyroid, a thyroid cancer was suspected. Needle aspiration was done which yielded 5 cc of colloid fluid followed by almost complete disappearance of the thyroid nodule. The HARD thyroid nodule was BENIGN pala . The HARD thyroid nodule turned out to be BENIGN after all.

25. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Some reflection and learning points and issues: What are the alert signs for thyroid cancer? What were the alert signs for thyroid cancer present in this patient? Am I justified to suspect thyroid cancer present in this patient? Can my palpation and interpretation be wrong? In retrospect (or looking back), is there really something wrong with with my palpation and interpretation of HARD SOLID thyroid nodule? In retrospect (or looking back), can I be faulted in placing Thyroid Cancer as my primary clinical diagnosis? Are all HARD thyroid nodules cancerous? What are benign thyroid disorders that can present as HARD thyroid nodules? ROJoson’s tips on management of similar situation

26. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: What are the alert signs for thyroid cancer? The alert signs for thyroid cancers are: Thyroid nodule / nodules which are solid, hard, non-tender, and fixed with signs of skin invasion; with neck nodes; and with distant mass suspicious for metastasis. A single alert sign is enough to make one suspect thyroid cancer. Multiple alert signs = greater suspicion

27. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: What were the alert signs for thyroid cancer present in this patient? The alert signs for thyroid cancers are: THYROID NODULE / nodules which are SOLID, HARD , NON-TENDER , and fixed with signs of skin invasion ; with neck nodes ; and with distant mass suspicious for metastasis .

28. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: Am I justified to suspect thyroid cancer present in this patient? YES, because based on my physical examination ( and my interpretation of my findings), I felt the thyroid nodule to be HARD, SOLID, and NON-TENDER which are considered a lert signs for thyroid cancers with heaviest weight given to the HARD consistency. (hard – feel approximates the hardness of a bone; soft – feel approximates the softness of the lip; FIRM – feel approximates the firmess of the tip of the nose)

29. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: Can my palpation and interpretation be wrong? YES, because these are just personal perceptions and interpretations. I am ready to accept my being wrong as there is no such thing as 100% certain in medicine all the time. That’s the reason, why I have primary and secondary diagnoses. Primary diagnosis means the first suspect. Secondary diagnosis means the next probable if the primary diagnosis is determined on further examination to be NOT the case.

30. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: In retrospect (or looking back), is there really something wrong with with my palpation and interpretation of HARD SOLID thyroid nodule? I don’t think so. I really felt the nodule was hard and I couldn’t elicit fluctuancy on the nodule. If I could elicit fluctuancy , then I will say the nodule was cystic and not solid. How to elicit FLUCTUANCY in a mass or nodule.

31. t Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: In retrospect (or looking back), is there really something wrong with with my palpation and interpretation of HARD SOLID thyroid nodule? The nodule was really hard because of a very tense cyst. SO, LESSON LEARNED: A VERY TENSE CYST CAN PRESENT AS A SOLID HARD MASS.

32. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: In retrospect (or looking back), can I be faulted in placing Thyroid Cancer as my primary clinical diagnosis? NO, I don’t think so. I rightfully used the process of pattern recognition in making the diagnosis: HARD SOLID THYROID NODULE is a reliable clinical pattern for THYROID CANCER, though not always 100%. It just so happened that the thyroid nodule turned out to be a very tense cyst that presented with HARD and SOLID characteristics.

33. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: Are all HARD thyroid nodules cancerous? NO, as shown in this particular patient. The hard thyroid nodule turned out to be BENIGN PALA !

34. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: What are benign thyroid disorders that can present as HARD thyroid nodules? Aside from a tense colloid cyst, o ther thyroid disorders that can present as HARD SOLID THYROID NODULES and which are NOT CANCER are the following: Chronic thyroiditis Long standing colloid adenomatous goiter with macrocalcification (which produce hard consistency)

35. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Reflection and learning points and issues: What are the common options for laboratory diagnostic procedures if one needs to evaluate further a HARD thyroid nodule? Needle aspiration +/- biopsy Ultrasound

36. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala ROJoson’s tips on management of similar situation Always remember that not all HARD thyroid nodules are thyroid cancers. Majority will be though. A hard thyroid nodule may be a tense cyst. A very tense cystic thyroid nodule can give a feel and perception of a solid nodule.

37. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala ROJoson’s tips on management of similar situation Other thyroid disorders that can present as HARD SOLID THYROID NODULES and which are NOT CANCER: Chronic thyroiditis Long standing colloid adenomatous goiter with macrocalcification (which produce hard consistency)

38. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala ROJoson’s tips on management of similar situation Use clinical pattern recognition to process a clinical diagnosis (basically the so-called reliable alert signs). In more than 90% of the time, you will be correct in your diagnosis. However, be vigilant of the 10% error. Change your diagnosis right away once you discover your primary diagnosis is not the case. You won’t be faulted for this “honest” error.

39. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala ROJoson’s tips on management of similar situation Laboratory diagnostic procedures for evaluating further a HARD thyroid nodule usually consist of NEEDLE ASPIRATION +/- BIOSPY and / or ULTRASOUND. Either one may be sufficient; at times, the two may be needed for some justifiable reasons.

40. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala ROJoson’s tips on management of similar situation Needle aspiration is the most direct way of getting to the diagnosis (especially whether solid or cystic and the pathology if biopys is done). This can be done in the clinic if the thyroid nodule is palpable.

41. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala ROJoson’s tips on management of similar situation Ultrasound is an indirect way of diagnosis as it just creates images of the thyroid thyroid and nodules if present. Needle evaluation is a more direct way as it attempts to get a sample of cells / tissues for biopsy. Ultrsound can be helpful in detemining whether a hard thyroid nodule is hard solid or tense cyst.

42. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala SO, in this MAR, The HARD thyroid nodule was BENIGN pala . The HARD thyroid nodule turned out to be BENIGN after all . The HARD thyroid nodule turned out to be a tense cyst that gave a feel of being SOLID. Take note of these realities that can happen.

43. Contents What is a medical anecdotal report or MAR? Narration Insight / Reflection MAR Title: HARD Thyroid Nodule – Benign Pala Reporter : Dr. Reynaldo O. Joson Date of Medical Observation: 2024 Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Summary Take Away

44. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR : HARD Thyroid Nodule – Benign Pala GIST of MAR A 55-year-old Filipino female presented with a thyroid nodule of 2 to 3 years in duration. Because physical examination revealed a HARD solid thyroid nodule on the right thyroid, a thyroid cancer was suspected. Needle aspiration was done which yielded 5 cc of colloid fluid followed by almost complete disappearance of the thyroid nodule. The HARD thyroid nodule was BENIGN pala . The HARD thyroid nodule turned out to be BENIGN after all. Summary Take Away

45. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala MAR: HARD Thyroid Nodule – Benign Pala Some reflection and learning points and issues: What are the alert signs for thyroid cancer? What were the alert signs for thyroid cancer present in this patient? Am I justified to suspect thyroid cancer present in this patient? Can my palpation and interpretation be wrong? In retrospect (or looking back), is there really something wrong with with my palpation and interpretation of HARD SOLID thyroid nodule? In retrospect (or looking back), can I be faulted in placing Thyroid Cancer as my primary clinical diagnosis? Are all HARD thyroid nodules cancerous? What are benign thyroid disorders that can present as HARD thyroid nodules? ROJoson’s tips on management of similar situation Summary Take Away

46. Take Away in relation to Patient Empowerment Be always in touch with reliable medical information on “ HARD Thyroid Nodule .” Knowledge is power; it gives power. Use the 4Ks of Patient Empowerment: Kaalaman , Kakayanan , Karapatan and Kapangyarihan to gain greater control over decisions / make better decisions on management of “HARD Thyroid Nodule” as part of your health management. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

47. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. This ends my PEP TALK today on: Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala

48. t Reminder after the PEP Talk: Take the Online Learning cum Evaluation Test Exercise (OLETE) for mastery of learning and have a perfect score to get a Certificate. Link is in Chat Box.

49. Reminder: 25 OLETE Certificates = 1 Voucher for ROJoson Medical Consultation either Face-to-Face or Telemedical.

50. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. ROJOSON’S REQUEST: FEEDBACK TO THIS PEP TALK! Pls. type in your feedback in the chat box during the open forum and before we adjourn! Thank you!

51. Med Anecdotal Report - HARD Thyroid Nodule – Benign Pala Empowerment objective - for laypeople to have an essential  understanding on “HARD Thyroid Nodule – Benign Pala ” as part of their health management. LET’S NOW HAVE A GROUP PICTURE TAKING BEFORE WE START Q&A AND INTERACTIONS! Pls. turn on your video! Show your face!