Thyroid Disease PE

Subjective:
Chief Complaint:
Thyroid nodules monitoring

History of Present Illness:
Clara Winslow presents for monitoring of thyroid nodules. She has a known history of thyroid nodules under surveillance. There are no reported symptoms of neck pain, dysphagia, odynophagia, hoarseness, dyspnea, or compressive symptoms. She does not report any recent changes in voice, unintentional weight loss, night sweats, or fever. There is no history of prior thyroid surgery. There are no complaints of cervical lymphadenopathy, palpitations, heat or cold intolerance, or changes in appetite. There is no reported history of radiation exposure to the head or neck. No previous fine needle aspiration or biopsy has been performed. There are no symptoms suggestive of hyperthyroidism or hypothyroidism. There is no family history of thyroid malignancy or other endocrine neoplasia. No prior treatment for thyroid disease is documented. The patient denies any recent upper respiratory tract infections or trauma to the neck. There is no report of sleep disturbances, snoring, or nocturnal symptoms related to the thyroid nodules. The nodules have been monitored with serial imaging, with the most recent ultrasound performed on January 10, 2026.

Past Medical History:
History of thyroid nodules under surveillance. No history of prior thyroid surgery. No history of radiation exposure to the head or neck. No previous fine needle aspiration or biopsy has been performed. No prior treatment for thyroid disease is documented.

Past Surgical History:
No history of prior thyroid surgery.

Family History:
There is no family history of thyroid malignancy or other endocrine neoplasia.

The Review of Systems:
No neck pain
No dysphagia
No odynophagia
No hoarseness
No dyspnea
No compressive symptoms
No recent changes in voice
No unintentional weight loss
No night sweats
No fever
No cervical lymphadenopathy
No palpitations
No heat or cold intolerance
No changes in appetite
No symptoms suggestive of hyperthyroidism or hypothyroidism
No recent upper respiratory tract infections
No trauma to the neck
No sleep disturbances
No snoring
No nocturnal symptoms related to the thyroid nodules

Objective:
Physical Examination:
General:
- Facial expression: Not assessed during telehealth visit
- Facial symmetry: Not assessed during telehealth visit
- Hair distribution: Not assessed during telehealth visit

Neck:
- Examine for adenopathy: Patient reports that lymph nodes are normal in the right thyroid and lymph nodes are normal in the left thyroid based on most recent imaging
- Palpate the thyroid gland:
  - Inspection from the front: 
    - Thyroid cartilage: Not assessed during telehealth visit
    - Cricoid cartilage: Not assessed during telehealth visit
    - Thyroid gland: Not assessed during telehealth visit
  - Palpation from behind:
    - Isthmus: Not assessed during telehealth visit
    - Right lobe: Not assessed during telehealth visit
    - Left lobe: Not assessed during telehealth visit
    - Size: Not assessed during telehealth visit
    - Shape: Not assessed during telehealth visit
    - Consistency: Not assessed during telehealth visit
    - Nodules: Not assessed during telehealth visit
    - Tenderness: Not assessed during telehealth visit

Test Results:
Ultrasound of the neck and thyroid performed on January 10, 2026, demonstrated a 17 mm hypoechoic TR 5 nodule in the lower right thyroid lobe with small echogenic foci, qualifying for biopsy based on TI-RADS criteria. The right upper thyroid lobe contains a stable TR 4 nodule. The isthmus contains a stable 12 mm TR 4 nodule. The left upper thyroid lobe contains a stable 6 mm TR 4 nodule. The right thyroid lobe measures 4.1 cm x 2.0 cm x 1.2 cm with homogenous echotexture and normal lymph nodes. The isthmus measures 0.3 cm. The left thyroid lobe measures 3.7 cm x 1.7 cm x 1.1 cm with homogenous echotexture and normal lymph nodes. The right lower nodule measures 17 x 12 x 16 mm, is highly suspicious (TR 5), solid, hypoechoic, wider than tall, with smooth margin and punctate echogenic foci. The right upper nodule measures 7 x 5 x 5 mm, is moderately suspicious (TR 4), solid, hypoechoic, wider than tall, with smooth margin and no comet-tail artifacts. The isthmus mid nodule measures 12 x 8 x 12 mm, is moderately suspicious (TR 4), solid, hypoechoic, wider than tall, with smooth margin and no comet-tail artifacts. The left upper nodule measures 6 x 6 x 6 mm, is moderately suspicious (TR 4), solid, hypoechoic, wider than tall, with ill-defined margin and macrocalcifications.

Assessment:
Problem:
Clara Winslow is being monitored for multiple thyroid nodules, including a highly suspicious (TI-RADS 5) 17 mm hypoechoic nodule in the lower right thyroid lobe, which meets criteria for fine needle aspiration. Additional stable, moderately suspicious (TI-RADS 4) nodules are present in the right upper thyroid, isthmus, and left upper thyroid lobe.

Differential Diagnosis:
1. Suspicious thyroid nodule (TI-RADS 5) in the right lower lobe: The nodule is solid, hypoechoic, wider than tall, with smooth margins and punctate echogenic foci, raising concern for malignancy.
2. Benign or indolent thyroid nodules (TI-RADS 4) in the right upper lobe, isthmus, and left upper lobe: These nodules are stable in size and appearance, with features that are moderately suspicious but unchanged on serial imaging.
3. Multinodular goiter: The presence of multiple nodules in both lobes and the isthmus may represent a multinodular goiter, though the dominant nodule's suspicious features warrant further evaluation.