A 25-year-old female patient presents with self-detected neck nodule for 2 months. She has no symptoms of thyrotoxicosis or compressive symptoms associated with the nodule.

Question:  

"How to approach the diagnostic evaluation for patients presenting with a thyroid nodule?"

ANSWERs

1. Begin by confirming whether the neck mass is a thyroid nodule. Have the patient swallow, and observe if the nodule moves during swallowing to confirm the thyroid nodule.

2. Take a medical history:

   2.1 Assess symptoms of thyrotoxicosis, such as tremors, easy fatigue, increased appetite, weight loss, diarrhea, excessive sweating, etc.

   2.2 Look for compressive symptoms such as difficulty swallowing, a choking sensation, or breathing difficulties.

   2.3 Explore risk factors for thyroid cancer, like a family history of thyroid cancer or exposure to neck radiation.

3. Conduct a physical examination of the thyroid nodule, assessing tenderness, consistency, borders, and listening for thyroid bruit. Additionally, palpate the cervical lymph nodes. Look for signs of long-standing hyperthyroidism, including lid lag, lid retraction, exophthalmos, limited extraocular movements, onycholysis (plummer’s nails), etc.

4. Order TSH levels:

   4.1 Low TSH -> proceed to a thyroid scan. Treat hyperthyroidism if a hot nodule is detected; if a cold nodule is found, perform a thyroid ultrasound.

   4.2 Normal/High TSH -> proceed to a thyroid ultrasound.

5. Review ultrasound results, reported as ACR TI-RADS or ATA classifications. If suspicious for cancer (irregular margins, taller than wide, microcalcifications, rim calcification, evidence of extrathyroidal extension), consider fine-needle aspiration (FNA).

6. Interpret FNA results:

   6.1 Non-diagnostic -> repeat FNA.

   6.2 Benign -> follow up with a thyroid ultrasound result

   6.3 AUS (Atypia of Undetermined Significance) -> approximately 20% chance of cancer; consider repeat FNA, lobectomy, or molecular testing

   6.4 Suspicious or positive for malignancy -> proceed with thyroid surgery.

7. After surgery, manage accordingly:

If no malignancy is present, hormone supplementation may not be necessary after lobectomy, but in the case of total thyroidectomy, provide hormone supplementation until thyroid function normalizes.

If thyroid carcinoma is diagnosed, patients typically require radioactive iodine therapy followed by hormone supplementation.

8. Be cautious of post-thyroidectomy complications, such as hoarseness from recurrent laryngeal nerve injury or low calcium levels from hypoparathyroidism. Monitor these risks closely.

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