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Old 01-19-2013
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Thyroid Thyroid Nodule Workup

A 42-year-old woman with no significant past medical history presents for a routine health maintenance visit. On physical examination a solitary nodule is palpated in the thyroid. She denies pain, dysphagia, or hoarseness. She also denies fatigue, weight change, heat or cold intolerance, diarrhea, or constipation. There is no family history of thyroid cancer. Her serum thyroid-stimulating hormone level is normal.
Which of the following is the most appropriate next step in evaluation?
(A) Fine-needle aspiration
(B) MRI
(C) Radionuclide scan
(D) Thyroid lobectomy
(E) Ultrasonography
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Old 01-19-2013
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A or E??

A) FNAC is diagnostic but invasive

E) USG is non-invasive, can know whether its solitory nodule/dominant nodule in Munti0nodular goiter

will go with A
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i also think it as A.FNAC...(although invasive ,most likely the next step for nodule)

thanks
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its USG......accrdng to the workup of thyroid nodule given in uworld.....if USG shows lesion suspicious of malignancy, FNA is indicated.....
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fnac thats what mtb says
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Answer is (A) Fine-needle aspiration
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Thyroid nodule workup
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Quote:
Originally Posted by anomali View Post
its USG......accrdng to the workup of thyroid nodule given in uworld.....if USG shows lesion suspicious of malignancy, FNA is indicated.....
UW says diagnostic USG, I think it means USG guided FNAC
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Quote:
Originally Posted by aknz View Post
UW says diagnostic USG,I think it means USG guided FNAC

i guess....MTB says do FNA if thyroid tests turn out to be normal
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but wont u do a USG to see where exactly you do a FNAC?
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Quote:
Originally Posted by aknz View Post
A 42-year-old woman with no significant past medical history presents for a routine health maintenance visit. On physical examination a solitary nodule is palpated in the thyroid. She denies pain, dysphagia, or hoarseness. She also denies fatigue, weight change, heat or cold intolerance, diarrhea, or constipation. There is no family history of thyroid cancer. Her serum thyroid-stimulating hormone level is normal.
Which of the following is the most appropriate next step in evaluation?
(A) Fine-needle aspiration
(B) MRI
(C) Radionuclide scan
(D) Thyroid lobectomy
(E) Ultrasonography
i think since they are asking in evaluation. we should do the test which tells us something more regarding diagnosis. if i am interpreting that right, the answer would be A.

if the question were, which is next step? USG
the next best step? FNAC.
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Quote:
Originally Posted by alexia View Post
but wont u do a USG to see where exactly you do a FNAC?
kaplan surgery says FNAC is virtually risk free and easy to do. so i think the answer is FNAC. please do justify if i am wrong.
thank u
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This is a seriously confusing MCQ especially if you have seen the algorithms of UW as well as kaplan qbank for the managment of thyroid nodule.

AKNZ you said the answer is A, can u please tell the source of this question?

I still Think it should be USG, because we always start with a non invasive diagnostic test if it is available in the options even though it may not be the definitive test. Plus UW recommends it.
If question would have asked which is likely to give most information or lead to diagnosis then FNA would have been correct.

Last edited by Syndrome X; 01-19-2013 at 09:59 PM.
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Old 02-10-2013
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Quote:
Originally Posted by Syndrome X View Post
This is a seriously confusing MCQ especially if you have seen the algorithms of UW as well as kaplan qbank for the managment of thyroid nodule.

AKNZ you said the answer is A, can u please tell the source of this question?

I still Think it should be USG, because we always start with a non invasive diagnostic test if it is available in the options even though it may not be the definitive test. Plus UW recommends it.
If question would have asked which is likely to give most information or lead to diagnosis then FNA would have been correct.
It is from first aid.
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Old 02-10-2013
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You need histological diagnosis so do FNA.
USG is not going to help in any way in making a diagnosis.
You have to ask yourself-What am I achieving by doing a particular test? Does it make me any wiser regarding the diagnosis?
Only test which will give me a diagnosis is FNA.

Bottomline:

If you can feel a thyroid nodule>>>>>Stick a needle in! (FNA)
If you can't feel it/not sure >>>>Do an USG to localize followed by FNA (US guided FNA).

This is from The New England Journal of Medicine

Quote:
conclusions and recommendations

For the patient who presents with a nodule, as in
the case described in the vignette, the main concern
is to exclude the possibility of thyroid cancer,
even though the vast majority of nodules are benign
(Fig. 1). The initial evaluation should include
measurement of the serum thyrotropin level and a
fine-needle aspiration, preferably guided by ultrasonography.
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Last edited by Novobiocin; 02-10-2013 at 05:34 PM.
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Old 02-10-2013
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A.

See MTB2 p115.
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Old 02-10-2013
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Quote:
Originally Posted by Novobiocin View Post
You need histological diagnosis so do FNA.
USG is not going to help in any way in making a diagnosis.
You have to ask yourself-What am I achieving by doing a particular test? Does it make me any wiser regarding the diagnosis?
Only test which will give me a diagnosis is FNA.

Bottomline:

If you can feel a thyroid nodule>>>>>Stick a needle in! (FNA)
If you can't feel it/not sure >>>>Do an USG to localize followed by FNA (US guided FNA).

This is from The New England Journal of Medicine
UW question ID 3484:

If thyroid function tests are normal,then do the USG because patient has 5 % risk of malignancy.It will tell the nodule is benign or malignant.If it shows the features of malignancy,then do FNAC.

If there is family history of cancer and patient has nodule,even USG is normal,do FNAC.

This question says no family H/O of cancer,so I think answer is USG.
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Quote:
Originally Posted by aknz View Post
UW question ID 3484:

If thyroid function tests are normal,then do the USG because patient has 5 % risk of malignancy.It will tell the nodule is benign or malignant.If it shows the features of malignancy,then do FNAC.

If there is family history of cancer and patient has nodule,even USG is normal,do FNAC.

This question says no family H/O of cancer,so I think answer is USG.
USG cannot rule out malignancy...........only a FNA can.........period!
That's the reason the only answer is FNA.
I don't care what UW says but I am going to follow NEJM on this because they have the ultimate say for Medicine in general and USMLE in particular.
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Old 02-11-2013
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Default Thyroid nodules and cancer

Plz open the attachment
Attached Files
File Type: docx Thyroid nodules workup.docx (91.0 KB)
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Old 02-11-2013
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Thank you guys for coming back. It was confusing question just because of the UW Question Aknz mentioned.

every single association of endocrinology recommends FNAC to rule out malignancy in pt with euthyroid profile and thyroid nodule.

Agreed with Novobiocin. We just dont follow UW blindly.
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Old 02-13-2013
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Quote:
Originally Posted by aknz View Post
A 42-year-old woman with no significant past medical history presents for a routine health maintenance visit. On physical examination a solitary nodule is palpated in the thyroid. She denies pain, dysphagia, or hoarseness. She also denies fatigue, weight change, heat or cold intolerance, diarrhea, or constipation. There is no family history of thyroid cancer. Her serum thyroid-stimulating hormone level is normal.
Which of the following is the most appropriate next step in evaluation?
(A) Fine-needle aspiration
(B) MRI
(C) Radionuclide scan
(D) Thyroid lobectomy
(E) Ultrasonography
nodule isnot functional and need to do Fine Needle aspiration
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