What is the best next step for evaluating a 72-year-old woman with a 2- to 3-cm swelling at the base of the neck, just to the right of the trachea, and elevated Thyroid Stimulating Hormone (TSH) levels, presenting with hypertension and tachycardia?

From the Guidelines

The best next step for evaluating this patient is to perform a thyroid ultrasound. This 72-year-old woman presents with a 2-3 cm neck swelling in the anterior triangle that moves with swallowing, which is highly suggestive of a thyroid nodule. The elevated TSH level (8.03 μU/mL) indicates subclinical hypothyroidism, but this doesn't explain the nodule itself. According to the US Preventive Services Task Force recommendation statement 1, the serum TSH test is the primary screening test for thyroid dysfunction, and follow-up testing of serum T4 levels can differentiate between subclinical and overt thyroid dysfunction. However, in this case, the presence of a thyroid nodule necessitates further evaluation with imaging. Thyroid ultrasound is the preferred initial imaging study for thyroid nodules as it can characterize the nodule (solid vs. cystic), measure its exact size, identify additional nodules, and assess for concerning features that might suggest malignancy. Following the ultrasound, fine-needle aspiration (FNA) biopsy may be indicated depending on the sonographic characteristics and size of the nodule. This approach is particularly important given the patient's age, as thyroid nodules in elderly patients carry a higher risk of malignancy, even without typical risk factors like radiation exposure or family history. While the normal calcium levels suggest that hyperparathyroidism is unlikely, the thorough evaluation of the thyroid nodule remains the priority.

Some key points to consider in the evaluation of this patient include:

• The patient's age and the presence of a thyroid nodule increase the risk of malignancy 1
• The elevated TSH level indicates subclinical hypothyroidism, but this does not explain the nodule itself
• Thyroid ultrasound is the preferred initial imaging study for thyroid nodules
• Fine-needle aspiration (FNA) biopsy may be indicated depending on the sonographic characteristics and size of the nodule
• The patient's normal calcium levels make hyperparathyroidism unlikely, but the evaluation of the thyroid nodule remains the priority.

Given the lack of direct evidence that treatment of thyroid dysfunction based on risk level alters final health outcomes 1, the focus should be on evaluating and managing the thyroid nodule, rather than solely treating the subclinical hypothyroidism. Thyroid ultrasound is the best next step in the evaluation of this patient, as it will provide valuable information about the nature of the thyroid nodule and guide further management.

From the Research

Evaluation of Thyroid Swelling

The patient presents with a swelling in the anterior triangle of her neck, which moves superiorly when she swallows, indicating a possible thyroid gland issue. The laboratory findings show an elevated thyroid-stimulating hormone (TSH) level of 8.03, which is above the reference range of 0.5-4.7.

Next Steps in Evaluation

Given the patient's symptoms and laboratory results, the next step in evaluation would be to perform an ultrasound examination of the thyroid gland, as described in the study by 2. This non-invasive and radiation-free method can provide important information about the thyroid gland and help identify any potential abnormalities.

Laboratory Tests

In addition to the ultrasound examination, further laboratory tests may be necessary to determine the cause of the patient's elevated TSH level. The studies by 3, 4, 5, and 6 suggest that measuring free triiodothyronine (FT3) and free thyroxine (FT4) levels, as well as calculating the FT3/FT4 ratio, may be helpful in differentiating between various thyroid disorders. However, these tests may not be directly relevant to the patient's current presentation, and the decision to perform them should be based on the results of the ultrasound examination and other clinical factors.

Key Considerations

• The patient's elevated TSH level suggests hypothyroidism, but the absence of other symptoms such as weight gain, muscle weakness, or skin changes makes this diagnosis less likely.
• The swelling in the anterior triangle of the neck is consistent with a thyroid gland issue, and the ultrasound examination should help to confirm or rule out this possibility.
• Further laboratory tests, such as measurement of FT3 and FT4 levels, may be necessary to determine the cause of the patient's elevated TSH level, but these should be guided by the results of the ultrasound examination and other clinical factors.