Dr. ___________ has asked for consultation on this patient regarding regarding _______________.
Thank you for inviting us to see this patient.
Chief complaint: ___ year old male/female presents today for evaluation and treatment of a thyroid nodule.
Patient admits/denies to a history of radiation exposure.
Patient admits/denies to a history of dysphagia odynophagia.
Patient admits/denies to a history of horseness of voice.
My key findings of the ROS, Past Hx, Family Hx, and social Hx are:
ROS: Review of 12 systems was negative with exception of those things mentioned above in the HPI and weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.
Patient denies weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.
Past Medical History:
Past Surgical History:
Family History:
Patient admits/denies to a family history of pheochromocytoma, medullary thyroid carcinoma, or hyperparathyroidism
Social History:
Diet:
Exercise:
Smoking:
Recreational Drug use :
Education:
Occupation:
Lives with ____ where ____
Home Meds:
Allergies:
My key findings of this patient's Physical Exam are:
VITALS:
Pulse:
Blood Pressure:
Respirations:
Temperature:
Weight:
Height:
BMI:
GENERAL: sitting up/reclined in bed, awake, alert, and oriented
HEAD: normocephalic, atraumatic, no temporal wasting, negative chvostek sign
NOSE, MOUTH: lips and mucous membranes are moist, normal color of buccal mucosa
EYES: EOMI, PERLA, no proptosis
NECK: supple, thyroid normal in size, thyroid small, thyroid low set, no thyromegaly or masses
RESPIRATORY: clear to ascultation bilaterally
CARDIOVASULAR: S1S2, no murmurs/rubs/gallops
GI: soft, non-tender, + bowel sounds
LYMPHATIC: no cervicoclavicular adenopathy appreciated
MUSCULOSKELETAL: moving all extremities
EXTREMITIES: no edema present
NEUROLOGIC: monofilament sensed in all areas of the foot, vibratory sensation intact, fine/crude touch intact, pulses palpable, DTRs 2+, CN grossly intact
DERMATOLOGY: no xanthomas appreciated, no skin ulcers, no calluses, no onchyomycosis/dermatophyosis, no striae,
PSYCHIATRY: patient answers questions appropriately, appropriate affectcoherent thoughts without flight of ideas
Labs:
Thyroid:
TSH:
FT4:
TT4:
QT3:
Athyp:
AthyG:
Calcitonin:
Thyroglobulin:
Assessment:
Diagnostic Plans:
Thyroid ultrasound (ultrasound) - solid or complex nodules more likely to be malignant than cystic nodules. Ultrasound is test of choice for evaluation of thyroid nodule.
ATSH is necessary to evaluate thyroid function. An algorithmic approach to thyroid function testing is to first check thyrotropin (TSH) and no further tests if TSH normal (0.4-5.5 mU/L). If abnormal TSH is found, check T4 and resin uptake (RU) ratio, and calculate free thyroid index (FTI) as T4 x RU. A fine-needle aspiration (FNA) has the greatest yeild if the nodule is > 1.0 cm. The FNA is necessary to diagnose malignancy. FNA biopsy reported to be more cost-effective than ultrasound or iodine 131 scintigraphy as initial test for solitary palpable thyroid nodule.
Thyroglobulin pre- and post-surgery (can show metastases), calcitonin (random or after pentagastrin).
The thyroid scan 99m-Tc pertechnate was previously used, 123-I or 131-I being used more commonly. It is used to classify nodules as hot, warm or cold. Cold nodules more likely to be cancer (but 85% cold nodules not cancer); hot nodules may be hypervascular, repeat with radioiodine if done with 99m-Tc pertechnate; difficulty with nodules near isthmus or periphery and normal tissue over nodule may mask nodule. The thyroid scan is not useful for predicting malignancy in solitary thyroid nodule; retrospective review of 770 patients who underwent thyroidectomy for solitary thyroid nodule, 23% had cancer; thyroid scan showed 82% cold nodules (23% malignant), 13% indeterminate (36% malignant) and 5% hot nodules (23% carcinoma); of 83 patients undergoing FNAB, biopsies were interpreted as consistent with thyroid carcinoma in 12 (all 12 malignant), benign in 27 (2 malignant) and 44 were inconclusive; 7% incidence of malignancy interpreted as benign in FNAB is concerning. Radionuclide scan and ultrasound provide more limited information than FNA, so FNA should be first-line approach.
Exposure of upper body to radiation increases risk for malignancy, 32-57% overall incidence of malignancy in irradiated glands.
The recommended approach for nonpalpable incidental nodules is an ultrasound-guided fine-needle aspiration if family history of thyroid cancer or childhood history of head or neck irradiation. Ultrasound-guided fine-needle aspiration if ultrasonographic findings suggestive of malignancy : hypoechoic pattern, incomplete peripheral halo, irregular margin, internal microcalcification, and increased flow.
Therapeutic Plans:
Simple follow-up neck palpation is sufficient for most patients with nonpalpable nodules and nonpalpable nodules incidentally detected by thyroid imaging.
Benign nodules should be followed by neck palpation at 6 months then annually.
Based on FNA results, if normal cells are found, patients with cytologically benign nodules are best followed without treatment, most benign nodules remain stable in size and remain benign when monitored long-term, repeat biopsy or surgery should be done for nodules that increase in size; based on review of trials of thyroxine suppressive therapy for solitary and predominantly solid thyroid nodules, only 10-20% nodules decreased > 50% in response to therapy. Reliance on repeat FNA biopsy is preferable to surgery.
suppressive L-thyroxine is controversial and no longer recommended, see discussion under Medications
If hypercellularity - thyroid scan
If hot nodule - 131-I treatment (radioactive iodine) if hyperthyroid
Warm or cold nodule - surgery (follicular adenoma vs. carcinoma)
If malignant cells, surgery generally recommended. Consider expectant management due to risks of surgery and non-aggressive course of certain thyroid malignancies. Consider surgical excision for thyroid cysts not abolished by aspiration. Suspicious cytologic results should undergo surgery with intraoperative evaluation of nodule. Recommendations in pregnancy to manage similarly to nonpregnant patients with FNA for all nodules and thyroidectomy for those suspicious of papillary cancer, preferably during second trimester; else surgery can be delayed until after delivery.
Patient Education:
Return to Clinic:
We have discussed our diagnostic and treatment plans with the patients and family/friends that were present. All questions have been answered to the patient's satisfaction.
Thank you for inviting to see this consult!
Written by ___ _____________________ Time out_______
• CPT codes for fine needle aspiration
10021 without imaging guidance
10022 with imaging guidance
Description:
• < 5% malignant
ICD-9 Codes:
• 241.0 nontoxic uninodular goiter
• 241.1 nontoxic multinodular goiter
• 241.9 unspecified nontoxic nodular goiter
• 242.1 toxic uninodular goiter
• 242.10 toxic uninodular goiter without mention of thyrotoxic crisis or storm
• 242.11 toxic uninodular goiter with mention of thyrotoxic crisis or storm