Neck swelling

Patient details

Name

Mrs L.K.

Age / sex

34-year-old woman

Occupation

Accountant

Marital status

Married, two children

Seen

Endocrine surgery clinic, 12:00

Clerked

Endocrine surgery clinic, 12:15

Source

Patient herself, reliable

Referred by

Family doctor

Presenting complaint

“A swelling in the front of my neck for four months.”

History of presenting complaint

Mrs L.K. was well until four months ago, when she noticed a swelling in the lower part of the front of her neck, to the right of the midline, while looking in the mirror. It has grown slowly since. It is not painful and has never suddenly enlarged. Her voice has not changed. She has no difficulty swallowing food or drink, no difficulty breathing, including when lying flat, and no noisy breathing. Her weight is steady and her appetite normal. She does not feel unusually hot or cold, does not sweat more than usual, and has no palpitations, tremor, anxiety or trouble sleeping. Her bowels are regular, and her periods are regular and unchanged. She is not more tired than usual, and her skin and hair have not changed. She has noticed no change in her eyes, no double vision and no grittiness. She has felt no other lumps in the neck. She had no radiotherapy to the head, neck or chest as a child. No one in her family has had thyroid cancer or other gland tumours, though her mother had a goitre removed that was benign. She has no bone pain, cough or weight loss. She has lived all her life in a hill village.

Past medical history

No chronic illness. No previous thyroid disease or thyroid blood tests.

Past surgical history

Two normal deliveries. No operations.

Drugs and allergies

No regular medication. No amiodarone, lithium or thyroid tablets. No known drug allergies.

Family history

Mother: thyroid operation for a benign goitre at 50. No thyroid cancer.

Social history

Does not smoke. Uses iodised salt at home.

General examination

A calm, well-looking woman, sitting comfortably and not sweating. Speech and voice normal. Weight 63 kg.

Hands: warm and dry, no tremor of the outstretched fingers, no red palms, nails normal.

Eyes: no lid retraction, no lid lag, no protrusion of the eyes, movements full.

Legs: no thickening of the skin over the shins. Ankle reflexes normal, with normal relaxation.

Examination of the neck

Seated, neck slightly extended and exposed to the clavicles.

Inspection

A swelling is visible in the lower anterior neck on the right. It moves upwards when she swallows a sip of water and does not move when she puts out her tongue. No scars, no redness, no dilated veins over the neck or upper chest.

Palpation

From behind. A single nodule in the right lobe of the thyroid, 3 by 2.5 cm, firm, smooth, not tender, moving with swallowing. Its lower border can be felt above the clavicle. The left lobe and isthmus are not palpable. Trachea central. No enlarged lymph nodes in the anterior or posterior triangles or the supraclavicular fossae. Both carotid pulses felt.

Percussion and auscultation

Resonant over the upper sternum. No bruit over the gland.

Pemberton's test

Negative: no flushing of the face or distension of neck veins on raising both arms for one minute.

Other systems

Chest: clear.

Heart: first and second heart sounds normal, no murmurs.

Abdomen: soft, no masses.

Summary

Provisional diagnosis

Solitary thyroid nodule of the right lobe, clinically euthyroid. Malignancy to be excluded.

Plan

• Thyroid stimulating hormone, with free T4 if it is abnormal. Serum calcium.
• Ultrasound of the thyroid and neck nodes.
• Ultrasound-guided fine needle aspiration if the ultrasound features and size call for it.
• Isotope scan only if the thyroid stimulating hormone is suppressed.
• Examination of the vocal cords before any operation.

Clinical signs related to this case

The signs you should look for in any patient with a thyroid swelling. For each one, know how to elicit it and what a positive result means.