24 y/o male non-smoker, w/ no significant PMHx presents to ED with ℅ throat pain x 2 months. Pt states the throat pain is 8/10, does not radiate, and has been getting worse over the past few days. He has been taking OTC Aleve for the pain with minimal relief. Pt is also experiencing odynophagia, fatigue and changes in his voice. He states “I have to speak much louder to get my voice out”. He also admits to wt loss in the past month (he can not quantify amount of weight loss, but states his pants are too loose). Pt is currently here on vacation from Gayana x 3 week.  Denies any SOB, fever, chills, night sweats, palpitations, coughing, voice hoarseness, drooling, ear pain, jaw pain, neck pain, abdominal complaints, or sick contacts.

DDX: Most dangerous to least dangerous.

1. Epiglottitis, Retropharyngeal abscess, Peritonsillar abscess, Throat cancer, —-must be ruled out first.
2. Goiter/ nodules
3. Pharyngitis

Past Medical History:

none

Past Surgical History: none 

Medications:

none

Allergies:

Denies drug, environmental or food allergies.

Family History:

Paternal Grandmother – breast cancer

Denies family h/o heart arrhythmia, heart disease, lung disease, CVA, or other cancers.

Non-smoker

Exposed to second-hand smoke for 10+ years

ROS:

General denies fevers, chills, H/A, or weakness.

Skin, and nails – denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus,

Hair- no change in hair texture or distribution.

Head – denies head trauma

Eyes – does not wear glasses; denies visual disturbance, lacrimation, photophobia, or pruritus.

Ears – denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/Sinuses –denies nasal congestion, discharge, epistaxis or obstruction.

Mouth and throat – denies bleeding gums, sore tongue, sore throat, mouth ulcers, or voice changes.

Neck – denies lumps, stiffness/decreased range of motion.

Breast – denies lumps or pain.

Pulmonary System – denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.

Cardiovascular System –  Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal System – denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, abdominal pain, diarrhea, change in bowel habit, hemorrhoids, constipation or melena.

Nervous System – denies H/A,  weakness, Denies seizures, loss of consciousness, sensory disturbances, ataxia, change in cognition/mental status/memory.

Musculoskeletal System – denies pain; denies deformity/swelling, redness, or arthritis

Peripheral Vascular System – denies SOB, intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System –denies any blood transfusions, anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine System – denies polyuria/polydipsia/polyphagia, heat or cold intolerance, goiter, excessive sweating, hirsutism.

Psychiatric – denies depression/sadness, anxiety, obsessive/compulsive disorder, seeing a mental health professional, taking psychiatric medications.

Physical

General: 24 y/o male , AO x3. Patient is well developed, and well groomed. he looks her stated age and doesn’t appear to be in any acute distress.

Vitals BP: 111/73, HR: 60, T: 98.1F oral R: 16 Sp02: 100%   -WNL

PE

Gen: AOx3, sitting comfortably in bed, in no acute distress

Skin: warm & moist, good turgor. Non-icteric, no cyanosis no lesions noted, no scars, tattoos.

Hair: average quantity, and distribution.

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout.

Ears: Auditory acuity intact to whispered voice AU.

Nose: nose patent,

Throat: mucosa pink and moist, oropharynx clear,

Neck: Prominent thyroid cart, no swelling redness, or tenderness on palpation.

EYES: PERRLA, EOMI, anicteric, no erythema, no discharge

Cardiology: normal S1 and S2 no murmurs or extra heart sounds, noted on auscultation carotid pulses are 2+B/L no bruit noted, no JVD noted.

Respiratory: chest non-tender to palpation, Lat to AP diameter 2:1 with symmetrical rise, Respirations unlabored/no use of accessory muscles noted no evidence of trauma, no rales, crackles wheezing, or rhonchi noted on exam.

Gastroenterology: Soft, non-distended, non-tender, normal BS X4, no Guarding, no Rebound

Musculoskeletal: mild FROM, with no swelling, deformity, or erythema, no tenderness, or pain on palpation.

Neurology: A&O x3, mild decreased sensation to right face/arm/leg, no focal neuro deficit. normal strength

Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Rectal and Genital exam was not performed due to lack of privacy in ED. (over-crowded bed placed without curtain)

Assessment: pt with throat pain x 2 months, non-specific wt loss, fhx of breast cancer, second hand exposure to smoking.

Transferred to main ED: for further work up

Plan

Tylenol (975mg) for pain

Order labs:

CBC- ordered- results WNL

BMP-ordered- results WNL

TSH-ordered- results: 2.25 WNL

T3-ordered- results: 95 WNL

T4 ordered results: 7.0 WNL

Imaging -CT neck soft tissue w/IV contrast:

Impression: CT scan shows mixed/low attenuation within the left and right lobes of the thyroid gland raising suspicion of a multinodular goiter.

Plan:

Outpatient ENT referral

Outpatient Endocrinologist referral- Pt may need Fine needle aspiration (FNA) biopsy

Tylenol for pain as needed.

Patient information:

• Your CT scan results show evidence of thyroid nodules.
• Thyroid are very common almost half of all people have at least one thyroid nodule although most do not know about it.
• Thyroid nodules can be caused by many different conditions
• Reassuringly, approximately 95 percent of all thyroid nodules are caused by benign (noncancerous) conditions.
• You will need to f/u with an ear nose and throat specialist as well as an endocrinologist for further evaluation of these nodule.