CCE-CBD-195

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between diffuse vs nodular goitre?
• Prompt: What features would raise suspicion for thyroid malignancy?

Q2. What are your initial management steps?

• Prompt: What investigations are required at this stage?
• Prompt: When would you refer for endocrinology or surgical review?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you reassure her regarding the likely benign nature of goitre?
• Prompt: What follow-up plan would you implement?

Q4. What preventive measures can help reduce her risk of thyroid disease progression?

• Prompt: What role does iodine intake play?
• Prompt: When should she seek further medical attention?

Q5. What are the red flags that would necessitate urgent referral or intervention?

• Prompt: What clinical features suggest thyroid malignancy or airway compromise?
• Prompt: How would you manage a rapidly enlarging goitre?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Goitre is an enlargement of the thyroid gland and can be diffuse or nodular, with benign and malignant causes.

Differential Diagnoses:

1. Benign Multinodular Goitre (Most Likely Diagnosis)
   • Key features: Gradual thyroid enlargement, no pain, no compressive symptoms.
   • Common in iodine-sufficient areas, often hereditary.
2. Autoimmune Thyroid Disease
   • Graves’ disease (hyperthyroidism): Goitre, palpitations, heat intolerance, weight loss.
   • Hashimoto’s thyroiditis (hypothyroidism): Goitre, cold intolerance, weight gain.
3. Thyroid Cysts or Benign Nodules
   • Key features: Palpable nodules, usually asymptomatic.
   • Diagnosed with thyroid ultrasound and fine-needle aspiration (FNA).
4. Thyroid Malignancy (Red Flag Cause)
   • Key features: Firm, fixed nodule, rapid growth, hoarseness, lymphadenopathy.
   • Requires urgent ultrasound and FNA biopsy.
5. Iodine Deficiency Goitre
   • Less common in Australia due to iodised salt.

Most Likely Diagnosis:

• Benign multinodular goitre based on gradual, non-tender enlargement without systemic symptoms.
• Requires confirmation with thyroid function tests (TFTs) and ultrasound.

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Q2: What are your initial management steps?

Answer:

1. Confirm Diagnosis with Investigations

• Thyroid Function Tests (TFTs) – Assess hyper/hypothyroidism.
• Thyroid ultrasound – Identify nodules, assess vascularity.
• Fine-needle aspiration (FNA) biopsy – If nodules are suspicious (>1 cm, solid, hypoechoic).
• TSH receptor antibodies, anti-TPO antibodies – If autoimmune thyroiditis suspected.

2. Symptomatic Management

• Monitor for compressive symptoms (difficulty breathing/swallowing).
• Reassure patient if benign findings.

3. Referral Criteria

• Endocrinology referral if nodules are suspicious or TFTs abnormal.
• Surgical referral if compressive symptoms or cancer suspicion.

4. Follow-Up Plan

• Review in 4-6 weeks with investigation results.
• Monitor every 6-12 months for growth or symptom progression.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms suggest a benign multinodular goitre, meaning your thyroid gland has grown slightly larger, but there are no signs of serious disease.”
• “This is usually not cancerous, and we will confirm with tests.”

Treatment Plan:

• “We will check your thyroid function with blood tests and perform an ultrasound.”
• “If a nodule appears concerning, we may do a biopsy (FNA).“
• “Most goitres are managed with monitoring, and only a few require surgery.”

Safety-Netting:

• “If you notice difficulty swallowing, voice changes, or rapid growth, return immediately.”
• “We will review you in 4-6 weeks with your test results.”

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Q4: What preventive measures can help reduce her risk of thyroid disease progression?

Answer:

• Maintain adequate iodine intake – Eat iodised salt, seafood, dairy.
• Monitor thyroid function – Especially if family history present.
• Avoid excessive iodine or radiation exposure.
• Regular medical follow-up – If nodules grow or symptoms develop.

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Q5: What are the red flags that would necessitate urgent referral or intervention?

Answer:

• Rapidly enlarging goitre or hard, fixed nodules.
• Hoarseness or voice changes (recurrent laryngeal nerve involvement).
• Difficulty swallowing or breathing.
• Family history of thyroid cancer.
• Lymphadenopathy or systemic symptoms (weight loss, night sweats).

Emergency Management of a Compressive Goitre:

• Urgent ENT/endocrinology referral.
• Consider thyroidectomy if airway compromise occurs.

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SUMMARY OF A COMPETENT ANSWER

• Correctly differentiates benign vs malignant causes of goitre.
• Identifies multinodular goitre as the most likely diagnosis.
• Orders appropriate investigations (TFTs, ultrasound, FNA).
• Provides lifestyle advice and monitoring.
• Recognises red flags requiring urgent referral.

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PITFALLS

• Failing to consider thyroid malignancy.
• Not ordering thyroid function tests or ultrasound.
• Reassuring the patient without ruling out red flags.
• Delaying referral for a suspicious or compressive goitre.

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REFERENCES

• RACGP Guidelines – Thyroid Disease Management
• GP Exams – Goitre

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to thyroid disease and goitre.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between benign and malignant causes of goitre.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including lifestyle and pharmacological interventions.
4.2 Recognises when urgent investigations or specialist referral is required.

5. Preventive and Population Health

5.1 Provides education on iodine intake and thyroid health.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD