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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history and conduct an appropriate examination. Please tell the facilitator your findings and suspected diagnosis.

Scenario

Jane Matthews is a 31-year-old woman who is pregnant for the first time. She is coming to see you because she has noticed a slight swelling in her neck just below her Adam’s apple.

The following information is on her summary sheet:

  • Past medical history

  • Nil significant. G1P0 18/40

  • Medication

  • Nil

  • Allergies

  • Nil known

  • Immunisations

  • Nil recorded

  • Cervical screening test

  • Normal this year

  • Family history

  • Nil significant

  • Social history

  • Married

  • Works as a hairdresser.

INSTRUCTIONS FOR THE PATIENT, JANE MATTHEWS

You are a 31-year-old married hairdresser. You are excited about being pregnant for the first time. Everything has been going well. Last week you were on holiday and you have just been looking at the photos again. Your neck looked a bit odd in the photos and you have now had a closer look in the mirror. There is a smooth swelling in the middle below your Adam’s apple.

You saw your GP last week about the pregnancy and the check-up was fine. You have booked today’s appointment just to sort out the swelling. You are not particularly worried about it.

CLINICAL EXAMINATION FINDINGS

You have a diffuse goitre but no other physical findings or symptoms.

The following information is on your summary sheet:

  • Past medical history

  • Nil significant. G1P0 18/40

  • Medication

  • Nil

  • Allergies

  • Nil known

  • Immunisations

  • Nil recorded

  • Pap smear

  • Normal this year

  • Family history

  • Nil significant

  • Social history

  • Married

  • Works as a hairdresser.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open-ended questions to explore patient’s ideas, concerns and expectations.

Specific questions

Weight loss, appetite, vomiting, lumps elsewhere

Heat tolerance, energy levels, palpitations, tremor, and difficulty swallowing solids or liquids

Change in voice, change in skin or hair, sweating, sleep pattern

Previous thyroid dysfunction, medications (specifically amiodarone, lithium)

Family history: any family history of thyroid problems, diabetes

Request permission to examine.

Examination

Inspection of the swelling

Palpation

  • — Site

  • — Size

  • — Consistency

  • — Tenderness

Movement on swallowing

Percussion—not needed

Auscultation of swelling for bruits

Palpation of lymph nodes of the neck

Examination for thyroid signs

  • — Pulse

  • — Tremor

  • — Eyes—for proptosis

  • — Warmth of peripheries

  • — Reflexes

  • — General skin changes

There is minor diffuse thyroid swelling and no other abnormality.

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