I haven’t looked in my archives, but I vaguely remember writing something quite a while back about enlargement of the thyroid gland, which is commonly called a goiter (the term is from the Latin “gutter” meaning neck). It’s time to talk about goiters again. Last week I received an e-mail from an obviously worried patient whose primary care doctor had just told her that she had an enlarged thyroid gland and that a blood test the week before had come back abnormal and that a thyroid ultrasound needed to be performed ASAP. The patient asked me if I had ever noticed that she had an enlarged thyroid gland. I answered her e-mail and in it asked that the doctor fax me a copy of the abnormal test result.
Back to basics
Before I tell you anything about the patient’s medical history and what I wrote in the e-mail (as well as a subsequent one, when I got the lab test result), I think we should review a bit about the anatomy of the thyroid gland. The gland is in the neck just below the larynx or so-called Adams apple. The gland is palpable in most people but it takes some practice to feel a normal-sized gland. First have the person sit in front of you and just look at their neck. If you notice a small protuberance just below the larynx go up and down when the person swallows, you have probably seen the thyroid gland. In precise anatomic terms, the gland is situated just below the cricoid cartilage ring which is the first ring below the larynx. The space between the bottom of the larynx and the cricoid cartilage is called the crico-thyroid membrane and it’s the place one is supposed to lance with a fountain pen cap to save a person’s life if there is an obstruction to airflow at the larynx. I wonder if anyone has actually done such a thing? I wonder how many people even own a fountain pen? Anyway, the thyroid gland consists of an isthmus in the midline which connects the 2 lateral lobes. With a normal-sized gland, the lateral lobes are quite small but most of the time the isthmus can be palpated with practice. If one sits facing the patient and the light is right, it is usually possible to see a butterfly-shaped form move up and down the neck with each swallow; the body of the butterfly is the thyroid isthmus and the wings are the lateral lobes with the superior lobes much more prominent than the inferior ones.
Back to the patient
I was astonished when the patient asked me if I had ever noticed that she had an enlarged thyroid gland. In fact, I had been caring for her type 1 diabetes for many years and had noticed first many years back that she had a very prominent neck. She and I had talked about her neck on many occasions- that should tell all doctors just how much patients listen to what the doctors says at clinic visits! I had known that the neck prominence was clearly not the result of a goiter since when she swallowed, the mass did not move up and down; the “problem” was simply a combination of large neck muscles and a fat ring that sat just above the thyroid isthmus which was barely palpable.
I had obtained thyroid function studies on a number of occasions, all of which were normal. The tests had been ordered as a routine since about 25% of patients with type 1 diabetes have chronic lymphocytic thyroiditis, an autoimmune disorder. I had also ordered thyroid function studies about 2 years earlier when the patient developed menstrual irregularities. Her thyroid test results had always been normal. So, it was not a surprise when I got the faxed copy of the thyroid test the patient’s primary care doctor had ordered that it was normal. I don’t know why the doctor told the patient the test result was abnormal.
So, I e-mailed the patient and told her not to bother with the ultrasound and that we would rediscuss her thyroid gland at the next appointment. I also told the patient that the primary care doctor was just trying to do a good job and that sometimes it’s hard to tell if a thyroid gland is enlarged even though as we discussed above it’s pretty easy if one knows how.
One more thing: the value of medical histories and physical examinations
This case should serve to remind all physicians that obtaining good medical histories and performing appropriate physical examinations remains an important aspect of medical encounters. Many years ago I found a cartoon in a throw-away medical journal for resident physicians. The cartoon showed two young physicians entangled in x-rays and laboratory test reports looking puzzled. One of the physicians was turned towards the other and said “maybe we should go back and get a medical history and do a physical examination.” I saved the cartoon because even in “the old days” there was concern that physicians were relying too much on laboratory tests to “make the diagnosis” without first starting with the tried and true. It amazes me how few of the younger physicians are skilled at obtaining medical histories and performing physical examinations. The stethoscope has largely turned into just a prop to hang around the neck. It’s time to resurrect the art and science of histories and physicals. Patient care will be all the better for it. I wonder how much my old cartoon would bring on E-Bay?
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