CASE WITH CHIEF COMPLAINT: 40 year old male CC: anterior neck mass

HISTORY:
In extracting a concise and accurate history of the patient’s present illness, first, establish a
rapport by greeting the patient, introducing yourself and offer a welcoming and comfortable
setting of consultation room. Secondly, gain consent with regard to asking personal and
confidential information that all information is confidential and private. A consent to be asked
again before physical examination to be done and explain the maneuvers to the patient so that
the patient will not get surprised at what procedures we are going to do.

INTRODUCTION:
“Good morning I am (state your full name) ,a medical student from University of Northern
Philippines, I will be taking your history, please bear with me, for it is important in your
diagnosis. I will be asking questions so I hope you’ll answer it truthfully and sincerely, you don’t
have to worry because anything about our conversation will remain confidential and will not be
disclosed without your consent except of course if under circumstances that it is really needed.”

IDENTIFYING DATA: May I know your name, gender, religion, occupation, and address, Sir?
RELIABILITY: 95%

CHIEF COMPLAINT:
Question: What is/are the reason/s of your visit today?
Answer: Anterior neck mass

To expound the chief complaint of the patient, which is “ANTERIOR NECK MASS”, we make
use of the 7 attributes of signs and symptoms. In the real setting, we cannot plot the 7 attributes
in chronological order, directly from the patient, but in the other way around, we will be the one,
as the physician, to arrange it chronologically from the patient’s story and follow ups for
elaborative, concise and accurate HPI.

HISTORY OF PRESENT ILLNESS:

ONSET:
● When did you first notice the lump?
● What were you doing when you first noticed it?
● Does the mass change in size?
● Have you had a recent illness?
Rationale:
Onset of a certain complaint indicates the
chronicity of the disease. Changes in size must
be noted whether it decreases or increases at a
specific timing so we can note the possibility of
malignancy.

PALLIATING/PROVOKING: Rationale: Asking the provoking and palliating

● What activities have you done to relieve the factors can help in narrowing down the
growing lump? diagnosis.
● Is there something that makes it worse? For example, there are foods, beverages,
therapies or physical activity that may palliate or
provoke the illness.

QUALITY : Rationale: To know the exact description of the

 ● Do you feel anything unusual when you swallow?
● Is it painful when you touch it? If it is painful, can cause and determine the best possible
you describe the pain?
● Can you describe what you felt when you tried to
palpate the mass?
REGION/RADIATION:
● If it is painful, can you pinpoint where? Is it identify the affected organ, which can help for
confined to this area only? If not, where else does the diagnosis of the disease.
it extend?
● Do you feel any swollen glands or lumps in your
neck aside from the pointed mass?
SEVERITY:
● From the Scale of 0-10 with 0 as no pain and 10
being the worst, how painful is it when it happens?
How about now?
TREATMENT
● Have you had the same lump before?
● Are you taking any medication to relieve the
symptom?
● Are they effective?
● How long have you been taking pain medication?
What is the dosage of your medicine? How
frequent are you taking it?
● Was it prescribed to you by a doctor?
● Did you experience any side effects that could
possibly affect the symptom that you're having
now?
ASSOCIATED SIGNS & SYMPTOMS:
● Aside from the reason for consultation, have you
noticed anything else that accompanies the onset
of your lump, like fever, spitting of blood?
UNDERSTANDING:
● What do you think caused this “lump”?
● Has this affected your daily living? How about your
family?
● What are your thoughts regarding your problem?
symptom, be able to better understand the
treatment.
Rationale: To determine the location and
Rationale: Assessing the severity of the
patient’s pain helps health care providers
ascertain if the pain is worsening or improving. It
also provides insight as to what the possible
next steps to take in the patient’s care plan.
Rationale:
To prevent potential harm to the patient during
treatment and avoid drug interactions. As well as
to determine whether the disease is improving or
deteriorating.
In addition, to determine drug toxicity and drug
adverse effects that may lead to certain
conditions or malignancy.
Rationale:
This should be noted to obtain a complete
description of the patient's illness.It usually
serves as an additional clue in diagnosing the
patient. Anterior mass might be with other
symptoms like pain, fever which is indicative of
infection etc.,
Rationale:
This is asked in order for the examiner to have
more information of the patient’s situation and
that the examiner can be aware of what impact
the complaint caused the patient. This can help
the examiner understand the situation more
deeply, especially in the emotional aspect of the
patient. And gauge the patient’s understanding
about the illness.
VALUES:
● What is your overall goal for this check-up?
● Do you have any beliefs, cultures and/or traditions
in your family that are important to note as we
manage your symptoms?
PAST MEDICAL HISTORY:
● Did you have any surgeries in the past,
specifically the neck area? If yes, did it have any
complication/s?
● Did you have any trauma?
● Did you have any exposure to radiation?
● Do you have any history of Cancer? Diabetes?
HIV? Malignancies?
● Are you currently taking any medications or
maintenance? If yes, please list.
FAMILY HISTORY:
● Do you have any family members that have
thyroid disease?
● Do you have any family members that have
head or neck cancer?
● Do you have any family members with thyroid
hormonal dysfunction (e.g. hypothyroidism,
hyperthyroidism)?
PERSONAL AND SOCIAL HISTORY:
● Do you smoke? If Yes, how many packs per
day? (Duration, frequency, method of use)
● Do you drink alcohol? If yes, how much and how
long have you been drinking?
● Have you had any exposure to radiation in your
work area?
REVIEW OF SYSTEMS:
Questions
General
Rationale:
Knowing the overall goal of the check up serves
as a guide for the practitioner of the next steps
to do. It serves as an objective (specific to
general) of the practitioner in the management of
the patient's illness.
Rationale:
Knowing what had happened in the past can help
the examiner determine if the history is related to
any acute complaints, and it can help the
examiner understand the cause of the present
complaint of the patient. These can give a much
better view of what is really happening as well as
the reason behind it, the possible triggers and to
understand the state of health of the patient
more.
Rationale:
The importance of this is to rule in and rule out
the genetically transferred diseases like cancers
& to know the probability of the patient acquiring
a certain disease.
Rationale:
To understand the risk factors and background
information that may be essential in formulating
the diagnosis.
Rationale
The importance of this is to not miss out the
 ● Has there been any unexpected change in your things that were not asked in present illness. It
weight? can also assuredly change management and
Skin could potentially lead to diagnosis and treatment
● Do you experience any changes in your skin? of an underlying, unknown medical issue. This
● Do you experience any redness, irritation or serves as a guide to help identify potential or
itchiness in your skin? underlying illnesses or disease states
● Do you experience hair loss? Thinning of the subjectively, thus allowing the examiner to
hair? prioritize systems for follow up in the objective
HEENT examination and also help obtain information
Head about a chief concern and also the history of
● Do you experience headaches? present illness.
● Did you have head injury?
Eyes
● Do you experience changes in vision?
● Do you feel pain in your eyes?
● Do you have any unusual eye discharges?
Ears
● Do you experience changes in hearing?
● Do you feel pain in your ears?
● Do you have any unusual ear discharges?
● Do you have any hearing loss?
Nose
● Do you have any unusual nasal discharges?
● Do you have nasal obstruction?
Mouth
● Are citrus fruit or tomatoes painful to eat?
● Do you have dental problems?
● Do you have any mouth ulcers?
Throat
● Did you experience painful swallowing?
● Did you have any difficulty swallowing?
● Has your voice been hoarse?
● Do you have any speech difficulties?
● Have you coughed up any blood?
● Do you have sore throats that won't go away? If
yes, how long?
Neck
● Do you experience stiffness on your neck?
Respiratory
● Do you have shortness of breath/difficulty of
breathing?
Cardiovascular
● Are you having any palpitations?
● Are you experiencing any irregular heartbeat?
Gastrointestinal
● Have you experienced any changes in your
 appetite?
Genitourinary
● Do you experience frequent urination?
● Do you notice any unusual discharge?
Musculoskeletal
● Do you have muscle weakness?
Psychiatric
● Do you feel any emotional distress, anxiety,
mood and personality changes in your situation
right now or in the past few days?
● Do you have any difficulty sleeping?
Endocrine
● Do you have any heat or cold intolerance?
● Do you experience excessive thirst or hunger?
● Do you sweat a lot?
DIFFERENTIALS:
HYPERTHYROIDISM

RULE IN RULE OUT

Expected PE Findings:
● Nervousness ● Weight gain
● Irritability ● Cold intolerance
● Heat intolerance ● Constipation
● Palpitations ● Memory impairment
● Tachycardia ● Bradycardia
● Tremor ● Hypothermia
● Easy fatigability ● Loss of hair
● Hyperactive tendon reflexes ● Reflex delay
● Thyroid Enlargement ● No history of hormone intake
● Exophthalmos ● Non tender neck mass
● Pretibial Myxedema
● Gynecomastia
● Audible bruit over the gland
● Mass located at the midline of the neck below Adam's
apple

Diagnostics

Laboratory:
● Decreased TSH
● Increased circulating T3/T4 levels
● Increased circulating thyroid Autoantibodies
○ Thyroid stimulating immunoglobulins(TSI)
○ Thyroid stimulating antibodies (TSAb)
● Radioactive iodine scan shows diffuse uptake through the gland of 45-90 percent.

Imaging:
● Chest radiography may identify congestive heart failure or pulmonary infections, often associated with progression to
thyroid storm.
 ● Nuclear thyroid scan
● Diffuse uptake in Graves disease
● Focal uptake in toxic nodular thyroiditis

Other Diagnostic test:

● Electrocardiogram
○ Sinus tachycardia most common
○ Atrial fibrillation (often in elderly patients)
○ Complete heart block (rare)

Management:
● Medication:
○ Propylthiouracil (PTU)
○ Methimazole (Tapazole)
○ Carbimazole
○ Beta-blockers (Propranolol)
● Radioactive Iodide
● Surgery (treatment of choice for large goiter)

SOLITARY THYROID NODULE

RULE IN RULE OUT

Expected PE Findings:
● Most patients are Asymptomatic
● Some exhibit signs and symptoms of altered levels of ● Trouble swallowing
thyroid hormones ● Size decreased or unchanged
● Hyperthyroidism ● Iodine Deficiency
○ NervousnessNervousness, heat intolerance, ● No exposure to radiation
diarrhea, muscle weakness, loss of weight and ● Painful
appetite.
 ● Increasing size of nodule
● Rapidly growing nodules and fixation to adjacent tissues.
● Pain is unusual
● Hoarseness or other voice changes that do not go away,
and due to recurrent laryngeal nerve paralysis
● Exposure to ionizing radiation and family history of
thyroid and other malignancies
● Vocal fold immobility.

Diagnostics

Laboratory:
● Normal or high TSH measurement increases risk of malignancy in parallel with serum TSH levels.
● Low TSH usually favors a benign nodule.

Imaging:
● Ultrasonography- determines the size and the presence of solid or cystic components
● Radionuclide imaging- malignant thyroid tissue concentrates less radioactive iodine than normal
● Cold nodules- hypofunctional
● Warm nodules- normal
● Hot nodules- hyperfunctional
● CT scan and MRI- has a limited role. Indications: suspected tracheal involvement (by invasion or compression, extension
into mediastinum, or recurrent disease)

Other Diagnostic test:

● Fine-Needle Aspiration Biopsy (FNAB)- diagnostic tool; where specimens are classified as malignant, benign,
indeterminate or insufficient

Management:
● If benign:
○ initial Tx: under observation or Levothyroxine suppressive therapy (administer 6-12 months to determine if nodule
size decreased, if yes medication is discontinued)
○ If size increases, repeat levothyroxine trial and FNAB
○ If thyroid nodules grow during therapy, SURGERY is indicated.
 ● If malignant
○ surgical removal

NODULAR NON-TOXIC GOITER

RULE IN RULE OUT

Expected PE Findings: ● Hyperthyroidism

● Asymptomatic, but when the goiter becomes large, it ● Panic attacks
causes obstructive symptoms such as dry cough, ● Mania
dyspnea and cough especially with exertion, dysphagia ● Pheochromocytoma
and shortness of breath ● Weight loss associated with malignancy
● Hoarseness of voice ● Grave’s disease
● Iodine Deficiency ● Plummer’s disease
● Dyshormonogenesis
● Goitrogens
● Hypothyroidism
● Diffuse goiter
● Nodular goiter
● Diffuse hyperplastic

Diagnostics

Laboratory:
● Normal level of TSH

Imaging:
● At least 1 clinically evident thyroid nodule (regardless of the total volume of the thyroid gland) or an enlarged thyroid gland
on ultrasonography with focal abnormalities of the echogenic structure lesions >1 cm in diameter

Other Diagnostic test:

 ● Fine-needle aspiration biopsy (FNB) and cytologic examination

Management:
● Surgery (nodules suspicious for malignancy, tracheal compression)
● Radioiodine therapy (age >40-60 years, goiter volume >60 mL, contraindications to surgery; not commonly used)
● Percutaneous ethanol injections (subtoxic nodules, simple cysts; not commonly used)

References:

Pynnonen, MA, Gillespie, MB, Rosenfeld RM, et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults.
Otolaryngol Head Neck Surg. 2017; 157(2 Suppl):S1-S30.

Singh Ospina N, Płaczkiewicz-Jankowska E, Jarząb B. Nontoxic Multinodular Goiter. McMaster Textbook of Internal Medicine.
Kraków: Medycyna Praktyczna.

Daniel J Kelley, M. D. (2021, December 23). Evaluation of solitary thyroid nodule. Overview, Differential Diagnosis, Benign Thyroid
Nodules. Retrieved April 25, 2022, from https://emedicine.medscape.com/article/850823-overview#a6

Andre Hebra, MD. (Mar 06, 2017 ) Solitary Thyroid Nodule Workup. Retrieved April 25, 2022 from
https://emedicine.medscape.com/article/924550-workup