A 48 year old post-menopausal woman with
a diffuse thyroid swelling more than 10 years:
1.Issues to be covered:
- pregnancy,puberty
- where she lives
- any medications:antithyroid,Lithium,Amiodarone
- women in reproductive years or >65
- hard & fixed suggest malignancy
- tenderness in thyroiditis
- Ask hyper/hypo symptoms
- Ask 3Ds:dysphagia,dysphonia,dyspnoea
- When does she first notice the swelling?
- Any past history of irradiation
- Any family history of thyroid cancer,FAP
- Inspect the fully extended neck
- Ask to swallow
- Elicit Pemberton’s sign
- Palpate including cervical glands
- Auscultation
- Immediate referral in case of suspected malignancy
- Perform TFTs and follow up to inform about the results
- Hyper:nearly always benign
- Nodule with normal TFT:Ultrasound scan and possible FNAC
Practice
10-Minute Consultation
Thyroid swellings
BMJ 2009;339:b2563Published 13 July 2009, doi:10.1136/bmj.b2563
In the given scenario, I would focus on what brings her to the consultation now as she has had diffuse thyroid swelling for 10 years.
ReplyDeleteRecent increase in size over a few months may indicate tumor.
Then symptoms of hyper or hypothyroidism and relapse and remission in clinical course would suggest autoimmune cause.
As mentioned , drug, family and previous medical history might give clue to an etiology.
Physical findings are important for management plan. In light of diffuse thyroid swelling, main possibilities are:
Grave's Disease,
Hashimoto's Thyroiditis,
Simple Goitre,
Drug Induced or Endemic goitre,and
Thyroid Tumor.
Investigations should also include thyroid autoantibodies, their presence supports autoimmune cases like Grave's disease and Hashimoto's thyroiditis.
Thyroid scintigraphy could differentiate toxic nodule, multinodular goitre and Grave's disease. If a nodule of multinodular goitre is 'Cold' on isotope scanning,it should be investigated as in a single nodule to rule out tumor.
Competing interests: None declared