A 65-year-old woman comes to the office to establish care. Her medical history is notable for hypothyroidism due to Hashimoto thyroiditis treated with levothyroxine. She does not have any symptoms at this time. There is no history of head or neck radiation exposure. On physical examination, vital signs are normal. The patient’s thyroid gland is enlarged. The right lobe is larger than the left, and a mobile 2-cm nodule is palpable in the lower pole. There is no palpable cervical adenopathy. Laboratory studies show a serum thyroid-stimulating hormone level of 2.0 µU/mL.
- Which of the following is the most appropriate diagnostic test to perform next?
- A. CT scan of neck
- B. FNA of thyroid nodule
- C. Thyoid uptake and 131 I scan
- D. Ultrasound of the neck
THYROID NODULES ARE COMMON!
- We miss most nodules on palpation. In fact, palpation fails to detect 50% of nodules <2cm and 90% <1cm. Fortunately, most thyroid nodules are benign.
- Risk factors for malignancy: personal history of ionizing radiation exposure, personal or family history of thyroid malignancy, extremes of age (<30 or >60yo), and male gender.
- Findings suggestive of malignancy include rapid nodule growth, a hard fixed nodule, dysphagia, vocal cord paralysis (hoarseness), and cervical LAD.
APPROACH TO WORK-UP:
- 2015 American Thyroid Association
- Take away: bad = hypoechoic, solid, or large
- Bethesda classification system
- Key point: benign FNA is still at risk for malignancy
Answer to the original question is D!
*Blog post based on Med-Peds Forum talk by Rebecca Moore, PGY4