A 40-year-old woman comes to the clinic after noticing a small swelling in the front of her neck. She has no pain, dysphagia, hoarseness, or difficulty breathing. She also has no hyper- or hypothyroid symptoms such as heat or cold intolerance, fatigue, or weight changes. Physical examination shows a mobile nodule in her left thyroid lobe. The patient has no history of neck irradiation or family history of thyroid illness. She currently takes no medications. The rest of the physical examination is unremarkable.
Which of the following is the best next step in evaluation of this patient?

Question

A 40-year-old woman comes to the clinic after noticing a small swelling in the front of her neck.  She has no pain, dysphagia, hoarseness, or difficulty breathing.  She also has no hyper- or hypothyroid symptoms such as heat or cold intolerance, fatigue, or weight changes.  Physical examination shows a mobile nodule in her left thyroid lobe.  The patient has no history of neck irradiation or family history of thyroid illness.  She currently takes no medications.  The rest of the physical examination is unremarkable. 
Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bedb_3522_8f63_59eb14141e44_MD0005_00 Patients with thyroid nodules should be evaluated for risk of malignancy (eg, family history, radiation exposure in childhood, cervical lymphadenopathy), compressive symptoms (eg, hoarseness, difficulty swallowing), and functional status (eg, euthyroid, hyperthyroid, hypothyroid). Definitive diagnosis of thyroid cancer can be made with fine-needle aspiration (FNA), but the goal of the clinical assessment is to determine which patients will require this invasive procedure. Initial testing to evaluate a thyroid nodule should include a serum TSH level and thyroid ultrasound. Patients with suspicious ultrasound findings (eg, large size, hypoechoic, microcalcifications, internal vascularity) or cancer risk factors should undergo FNA (Choice B). In addition, patients with normal or elevated TSH have a higher risk of malignancy and should be considered for FNA depending on ultrasound findings. Low TSH levels suggest a hyperfunctioning nodule, which has a lower risk of malignancy and should be evaluated with thyroid scintigraphy (Choice C). A "hot" nodule (increased isotope uptake in the nodule with decreased surrounding uptake) is rarely malignant and may be treated as benign hyperthyroidism. (Choice A) A CT scan of the neck can diagnose retrosternal goiter in patients with compressive symptoms (eg, hoarseness, dysphagia), but it is otherwise less sensitive than thyroid ultrasound for evaluation of nodules. (Choice D) Serum anti-thyroid peroxidase antibody titers are elevated in patients with chronic autoimmune (Hashimoto) thyroiditis, which usually presents with hypothyroidism and a normal-sized or diffusely enlarged thyroid. Educational objective: Thyroid nodules should be evaluated with TSH and thyroid ultrasound. Patients with suspicious findings on ultrasound should undergo fine-needle aspiration with cytology of the nodule. Patients with low TSH should have a radionuclide thyroid scan. References: Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. (http://www.ncbi.nlm.nih.gov/pubmed/19860577)

A 40-Year-Old Woman Comes to the Clinic After Noticing a Small