Thyroid Form
BASIC DATA (Fill in or use patient sticker)
Patients name and
civic registration nr
___________________________________
Patient ID
Hospital:
_________________________________
Surgeon:
Gender:
Consultant surgeon
Male
Assisted surgeon
Female
Civic Registration Nr:
Age of patient
Years
Date of referral:
-
-
Unknown:
Date of
acknowledgment for
referral at hospital:
-
-
Unknown:
Date of arrival of
referral/self referral
-
-
Unknown:
-
-
Unknown:
-
-
Unknown:
Date of first visit to :
specialist
Date of decision/On
waiting list for
operation
PREOPERATIVE DATA
1. Main Indication for Surgery
Malignancy
Excluding Malignancy
Continue to question 2
Compression Symptom
Recurrent cyst
Thyreotoxicosis  Go to question 1b
Completion thyroidectomy by cancer
Continue to question 2
Other indication __________________
1b. If thyreotoxicosis,
Grave’s disease  Go to question 1c
Multinodular goitre
Toxic adenoma
Thyroiditis
Other indication _______________________
Continue to question 1d
1c. If Grave’s disease: ophtalmopathy
1 av 5
Yes
No
1d. Subclinical thyreotoxicosis
Yes
No
1e. Medical treatment before surgery
If Yes, choose appropriate alternative
Yes
Beta Blocker
No
Antithyroid drugs
Thyroxin
Lugol’s solution
Cortisone
2. Intrathoracic goitre (
Yes (clinical assessment)
No
3. S-Calcium
Available  total mmol/___________ Ionised mmol/L__________
Not available
4. Cytology (choose appropriate alternative)
Not performed
No data available
Non-diagnostic or unsatisfactory
Benign
Atypia of undetermined significance or follicular lesion of undetermined significance
Follicular neoplasm or suspicious follicular neoplasm
Suspicious for malignancy
Malignant
5. Biopsy (choose appropriate alternative)
Not performed
No data available
Not representative
Benign
Malignancy
Biopsy performed under guidance of ultrasonography
Follicular/oxyphilic neoplasia
Yes
No
Cyst
Unclear case/malignancy suspected
6. Previous Thyroid operation
Yes → if Yes
bilateral procedure
unilateral procedure
No
7. Previous Parathyroid operation
Yes → if Yes
bilateral procedure
unilateral procedure
No
2 av 5
8. Indirect Laryngoscopy (choose appropriate alternative)
Not performed
Normal
Paresis of the right recurrent laryngeal nerve
Paresis of the left recurrent laryngeal nerve
Bilateral paresis of the recurrent laryngeal nerve
9. Voice Recording
Yes
No
OPERATION
10. Operation date (year/month/day) :
-
-
11. Operation time (skin-skin)
Available  minutes__________
Not available
12. Thyroid operation
Yes 
No
If Yes, choose appropriate alternative
Biopsy of thyroid gland (BAA00)
Exploration of thyroid gland (BAA05)
Incision of thyroid gland (BAA10)
Unilateral resection of thyroid gland (BAA20)
Bilateral resection of thyroid gland (BAA25 )
Isthmus resection of thyroid gland (BAA30)
Unilateral lobectomy of thyroid gland ( BAA40)
Lobectomy and resection of contralateral lobe of thyroid gland
(BAA50)
Thyroidectomy (BAA 60)
Other operation on thyroid gland ( BAA99)
13. Parathyroid operation (excl.re-implantation of parathyroid gland)
If Yes, choose appropriate alternative
Yes 
Biopsy of parathyroid gland (BBA10)
No
Exploration of parathyroid gland (BBA20)
Exstirpation of parathyroid gland (BBA30)
Subtotal parathyroidectomy(BBA40)
Parathyroidectomy (BBA50)
Other operation on parathyroid gland (BBA99)
14. Reimplantation/Transplantation of parathyroid gland (BBA70)
Yes
No
15. Lymph Node operation
Yes 
No
If Yes, choose appropriate alternative
Exploration of lymph nodes incl. biopsy (PJD10)
Exstirpation of lymph nodes (PJD41)
Central lymph node dissection (PJD41)
3 av 5
Central lymph node dissection (PJD41) and one-sided lat. lymph
node dissection (PJD51)
Central lymph node dissection (PJD41) and bilateral lat.
lymph node dissection (PJD51)
One-sided lateral lymph node dissection (PJD51)
Bilateral lateral lymph node dissection ( PJD51)
Reason for lymph node dissection
Prophylactic
Therapeutic
Diagnostic
16. Sternotomy (GAB20)
Yes
No
17. Thymus operation
Yes 
No
18. Other operation
Yes 
No
If Yes, choose appropriate alternative
Biopsy of thymus (GEC 00)
Transervical resection of thymus (GEC10)
Transternal resection of thymus (GEC13)
Transcervical thymectomy (GEC20)
Transternal thymectomy (GEC23)
Other operation on thymus(GEC96)
If Yes, code for surgical procedure and free text:
_______________________________________
19. Identification of right recurrent laryngeal nerve
Yes
No
20. Identification of left recurrent laryngeal nerve
Yes
No
21. Noted damage on recurrent laryngeal nerve peroperatively
Yes 
left
right
bilaterally
No
22. Intraoperative Nerve Monitoring
Yes
No
23. Identification of parathyroid glands (number) ___________ (0, 1, 2, 3, 4, 5, 6)
POSTOPERATIVE DATA
4 av 5
24. S-Calcium postop day 1
Available  total mmol/___________ Ionised mmol/L__________
Not available
25. Hypocalcemia which has required treatment with oral calcium
Yes
No
26. Hypocalcemia which has required treatment with iv calcium
Yes
No
27. Indirect laryngoscopy
Not performed
Normal
Paresis of the right recurrent laryngeal nerve
Paresis of the left recurrent laryngeal nerve
Bilateral paresis of the recurrent laryngeal nerve
28. Oral calcium therapy at discharge ( fixed dose)
Yes
No
29. Vitamin D analogue at discharge
Yes
No
30. Re-bleeding with operation(T81.0)
Yes
No
31. Wound infection (T81.4)
Yes
No
32. Other serious complication
If Yes, ICD code and free text:
Yes
_______________________________________
No
5 av 5