January 22, 2010

Neck Swelling

A 47 years old presented to A&E department because of choking. Apart from the problem, you notice something on her neck in which she defaulted treatment ten years ago. Below is the picture of her neck

1) What is your finding in the picture?

2) What is your differential diagnosis?

3) What further history you would like to obtain to make a provisional diagnosis

4) What investigation you would like to perform to support your provisional diagnosis.

5) What other signs that you would like to look for and why?


  1. HI, can u give the answers please. Thanks.

  2. 1) goitre
    2) Grave's, Hashimoto's, Subacute de Quervain, MNG, thyroid cancer, physiological,thyroid adenoma.
    3)Symptoms of hyper/hypothyroidism, painful goitre post-viral infection.
    4)TFT (free T3,T4,TSH), USS, FNA if solitary nodule.
    5) Thyroid acropachy, pretibial myxedema in Graves'.
    Tremulous hand (intention tremor) in thyrotoxicosis.
    Coarse facial appearance in hypo.
    Loss outer of eyebrow in hypo?
    Clothing appropriate or not.
    Dry hand in hypo, sweaty hand in hyper.
    Brisk and hanging reflex in hyper.
    Reduced reflex in hypo.

    Can you please check my answer?

  3. Your answer is good. but if you are asked to describe a picture, dont jump into a conclusion of a goitre. Just describe about your finding..

    you should comment on
    -Location of the mass
    - number of the mass
    -estimated size,
    - border is well defined or poorly defined
    - the overlying skin.
    - any vascularization
    -or any associated condition that u can observed in the picture

    2) you should bot only focus on your thyroid gland only when making differential.. it is not wrong but you should never made a straight conclusion based on observation only.. only after a thorough examination, then you can only make a firm diagnosis.. Yes, thyroid abnormalities is the most likely diagnosis.. but you should never forget also about the thyroglossal cyst, enlarged lymph node, lipoma, sebaceos cyst.

    Question 3 &4 is more detail in which you select the most likely diagnosis in which thyroid abnormalities.

    5) investigation can be blood, invasive and imaging. yes you are correct. thyroid function test, ultrasound and FNAC. in practical life, you should note the presentation is because of choking. therefore you should bear in mind that this patient have obstructive airway secondary to compression. Therefore, AP and lateral neck X ray can be helpful as your first evaluation.

    5)you got almost all of it..


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