You are seeing Mrs. Nguyen, a 52 year old woman, because she noticed a large swelling on her neck. Take a focused history and perform a focused head and neck examination.
History
- Clarifies location of mass (patient thinks it’s on the her right side of her neck)
- Onset of mass
- Progression in size
- Pain
- Dysphagia
- Odynophagia
- Change in voice
- Symptoms suggestive of hyperthyroidism
- Symptoms suggestive of hypothyroidism
- Systemic symptoms – weight loss, night sweats, anorexia
- Infectious symptoms – nausea/vomiting, fever, diarrhea
- Past medical history
- Personal history of malignancy
- Exposure to head and neck irradiation
- Exposure to tobacco, smoking, alcohol, and betel nuts
- Asks patient about ethnic origin (South East Asia)
- Personal history of thyroid disease
- Family history of thyroid disease
- Family history of head and neck cancer
Physical Examination
Inspection
- Comments on location of mass and any neck asymmetry
- Comments on stigmata of hyperthyroidism in head and neck (exophthalmos, lid lag, etc.)
- Comments on stigmata of hypothyroidism in head and neck (skin and hair changes)
- Comments on size of thyroid and observes thyroid as patient swallows
Palpation
- Comments on quality, size, and mobility of mass (mass is hard, irregular, and tethered)
- Comments on size of mass (~2 cm in diameter)
- Palpates all lymph node regions of the head and neck
- Names the regions which are being palpated
- Comments on the size, texture, mobility, and location of nodes that are identified
- Asks patient if palpation is tender
- Palpates both lobes of the thyroid; comments on size and nodularity
- Auscultates thyroid and comments on absence of bruits
Case 4 – Neck Mass