Thyroid nodule

Any individual mass palpable within the thyroid gland. Nodules are typically benign, may be hyperfunctioning, and may occur within a multinodular goitre, but always require assessment for possible malignancy. Diagnosis is usually clinical but assessment should always include serum hormone testing, and may require uptake scanning or ultrasound guided fine needle aspiration.

Has the patient lost or gained any weight unintentionally? 

Weight loss raises the possibility of malignancy though also occurs in patients with hyperthyroidism due to 'toxic nodule'.

Has the patient's appetite increased? 

Increased appetite with weight loss is a classic presentation of hyperthyroidism.

Does the patient complain of diarrhoea or a change in bowel habit? 

Increased passage of stools and diarrhoea may occur with any cause of hyperthyroidism.

Does the patient feel anxious or more irritable than usual? 

Change of mood may occur with hypothyroidism or hyperthyroidism though anxiety is typical of thyrotoxicosis.

Has the patient noticed a change in their energy? 

Many patients with hyperthyroidism have an abundance of energy and are unable to rest but can also feel tired. Apathetic thyrotoxicosis, in which the energy is paradoxically low, is unusual.

Is the patient sleeping normally? Are they more tired than usual? 

Many patients with hyperthyroidism will be unable to sleep well as they cannot relax despite feeling physically exhausted.

Does the patient feel hot or flushed? 

Heat intolerance is typical with hyperthyroidism.

Has there been a change in menstrual cycle? 

Oligomenorrhoea, scanty periods and amenorrhoea may all occur with hyperthyroidism.

Is there any chance the patient could be pregnant? 

The symptoms of thyrotoxicosis may mimic those of pregnancy.

Early foetal loss or miscarriage is more common in women with thyrotoxicosis.

Radioactive iodine is absolutely contraindicated in pregnant women.

Does the patient feel tremulous? Have they developed an overt shake? 

These are typical of thyrotoxicosis.

Has the patient developed any cardiac or respiratory symptoms? 

Ask whether the patient is having palpitations, or a racing or irregular heart beat, which might indicate tachycardia or atrial fibrillation.

Exertional chest pain or breathlessness may occur with cardiac ischaemia or thyrotoxic cardiomyopathy.

Does the patient complain of any changes to their skin or hair? 

Some patients develop generalised itching with thyrotoxicosis. Diffuse hair loss may also occur with thyroid dysfunction.

Who first noticed the change in their neck and when? 

Often family members will report that the swelling is long standing though the patient may only recently have noticed it, for example when a necklace or collar has become tight.

New onset or rapidly growing nodules require urgent assessment for possible malignancy.

Has the swelling appeared gradually or has there been any sudden change in the neck? 

Long standing gradual increase in the size of the thyroid, with some fluctuation is typical of a multinodular goitre. Sudden changes or rapid growth require urgent assessment.

Has there been any pain or tenderness in the neck? 

Thyroid cancer is usually painless.

Sudden painful swelling may indicate a bleed into a thyroid nodule or cyst.

Diffuse painful swelling is more indicative of thyroiditis.

Has their voice changed? 

Thyroid nodules should not affect the voice.

Changes in a patient’s voice should alert to the possibility of thyroid cancer particularly anaplastic thyroid cancer and requires urgent assessment.

Has the patient developed any difficulty swallowing? 

Document a history of dysphagia carefully. Many patients with an enlarged thyroid of any cause are aware of the lump and may describe swallowing as being uncomfortable.

Actual dysphagia, i.e difficulty swallowing certain foods or fluids, a feeling that food actually gets stuck, or the need to drink copious fluids to help wash solids down, requires urgent assessment.

This would be very rare with a thyroid nodule though may occur with a large or retrosternal multinodular goitre. New dysphagia strongly suggests malignancy.

Has the patient developed noisy breathing, started to snore, or finds it difficult to breathe in certain positions? 

These indicate incipient stridor and require urgent assessment. These features are rare with a thyroid nodule.

How are they personally affected by their neck swelling? 

Ask whether the patient is embarrassed or upset by the swelling. Is the patient or their family worried that this may be cancer? Is the swelling uncomfortable, or is the patient asymptomatic? 

Is there any family or personal history of thyroid swelling? 

Thyroid cancer, multinodular goitres and auto-immune thyroid disease may all occur more frequently within family members.

Is there any family history of thyroid cancer, multiple endocrine neoplasia or familial polyposis? 

All of these increase the likelihood of thyroid cancer and indicate that serum calcitonin should be checked.

Where is the family from originally? 

Multinodular goitre and endemic goitres are particularly common in certain geographical regions with iodine deficiency.

Has the patient previously undergone any radioactive iodine treatment, head and neck radiation, or were they exposed to Chernobyl fall out? 

Exposure to radiation increases the risk of hypothyroidism and of papillary thyroid cancer.

Does the patient's neck change on swallowing or sticking their tongue out? 

Thyroid nodules should move on swallowing. Lack of movement may occur with malignancy. Movement on tongue protrusion suggests an alternative pathology.

Has the patient noticed any other lumps or bumps? 

Lymphadenopathy in the neck or elsewhere is highly suspicious for a malignancy rather than a multinodular goitre.