Thyroid swellings

In the given scenario, I would focus on what brings her to the
consultation now as she has had diffuse thyroid swelling for 10 years.

Recent increase in size over a few months may indicate tumor.

Then symptoms of hyper or hypothyroidism and relapse and remission
in clinical course would suggest autoimmune cause.

As mentioned in the article, drug, family and previous medical history
might give clue to an etiology.

Physical findings are important for management plan. In light of
diffuse thyroid swelling, main possibilities are:
Grave's Disease,
Hashimoto's Thyroiditis,
Simple Goitre,
Drug Induced or Endemic goitre,and
Thyroid Tumor.

Investigations should also include thyroid autoantibodies, their
presence supports autoimmune cases like Grave's disease and Hashimoto's
thyroiditis.

Thyroid scintigraphy could differentiate toxic nodule, multinodular
goitre and Grave's disease.
If a nodule of multinodular goitre is 'Cold' on isotope scanning,it should
be investigated as in a single nodule to rule out tumor.

Competing interests:
None declared