What is the urgent care workup for a 52-year-old female presenting with thyroid swelling and tenderness for one week?

Urgent Care Workup for Thyroid Swelling and Tenderness

For a 52-year-old female presenting with thyroid swelling and tenderness for one week, the urgent care workup should include TSH measurement, ultrasound of the thyroid and central neck, and fine needle aspiration (FNA) of the nodule and any clinically suspicious lymph nodes. 1

Initial Assessment

• Thyroid Function Tests:

  • TSH measurement (primary test)
  • Free T4 from the same sample (prevents additional blood draws) 2
  • Consider anti-peroxidase antibodies (TPO-Ab) 2

• Imaging:

  • Ultrasound of thyroid and central neck (essential first-line imaging) 1
  • Consider ultrasound of lateral neck if suspicious features are present 1

• Fine Needle Aspiration (FNA):

  • FNA of the thyroid nodule is recommended as the first diagnostic test 1
  • FNA of any clinically suspicious lymph nodes 1
  • Ideally, TSH results should be known before FNA, but it may be performed during initial visit if practical 1

Suspicious Features to Evaluate

When evaluating thyroid swelling with tenderness, pay particular attention to these concerning features that increase the likelihood of malignancy:

• Clinical Features:

  • Firmness of the nodule
  • Fixation to adjacent structures
  • Rapid growth
  • Enlarged regional lymph nodes
  • Vocal cord paralysis
  • Symptoms of invasion into neck structures 1

• Ultrasound Characteristics:

  • Central hypervascularity
  • Microcalcifications
  • Irregular borders 1

Differential Diagnosis Considerations

Given the one-week duration of symptoms with tenderness, consider these specific conditions:

1. Subacute Thyroiditis:

   • Often presents with thyroid tenderness and swelling
   • May have fever (can present as fever of unknown origin) 3
   • Usually has elevated ESR
   • Typically has transient hyperthyroidism followed by hypothyroidism 2

2. Acute Thyroiditis:

   • Painful, tender thyroid
   • Often associated with infection
   • May have fever and elevated inflammatory markers

3. Hemorrhage into a Thyroid Nodule:

   • Sudden onset of pain and swelling
   • May have history of trauma or anticoagulation

4. Thyroid Malignancy:

   • Usually painless but can present with tenderness
   • More common in women, with peak incidence around age 45-49 1
   • Risk increases with suspicious ultrasound findings

Management Algorithm

1. If TSH is suppressed with elevated FT4:

   • Consider thyroiditis (especially with tenderness)
   • Beta-blockers for symptomatic thyrotoxicosis
   • NSAIDs for pain and inflammation
   • Consider short course of corticosteroids for moderate to severe symptoms 2

2. If TSH is elevated with low FT4:

   • Indicates primary hypothyroidism
   • Consider levothyroxine replacement 2

3. If ultrasound shows suspicious features:

   • Proceed with FNA regardless of TSH results 1
   • Cytologic examination results will guide further management

4. If fever is present:

   • Consider subacute thyroiditis 3
   • Check ESR/CRP to assess inflammation

Important Caveats

• A reassuring FNA should not override concerns if worrisome clinical findings are present 1
• Thyroid nodules are common (4-10% of adults), but less than 1% are malignant 4
• Women are more frequently affected by thyroid disorders than men (approximately 7:1 ratio) 5, 6
• Colloid goiter is the most common benign thyroid condition, while papillary carcinoma is the most common malignancy 5

By following this systematic approach in the urgent care setting, you can effectively evaluate thyroid swelling and tenderness while identifying patients who require further specialty evaluation or immediate intervention.