Thyroid exam Wishvan Ravindran wr715 MM Year 3 Clinical Skills Day 31/03/19 Thyroid exam Wishvan Ravindran wr715

Overview Quick History Clinical Examination Investigations Interpretation of results

Intro Wash hands- before history, before examining patient and after examining patient. Introduce full name and role, confirm patient’s name and DOB, offer chaperone. Permission- state purpose of exam ‘I’ve been asked to examine your thyroid gland which will involve me checking the glands in your neck, having a look at your face, and asking you to do a few movements. Would that be ok?’ Exposure- upper ⅓rd of sternum ‘I’d need to be able to see just below your neck’ Reposition- ensure there’s space behind the chair, could ask patient to move chair forward.

History Establish PC - SOCRATES, effect on patient’s life. Previous episodes, precipitants/exacerbating factors, alleviating factors Exclude/Establish: - Psychiatric symptoms: mood swings, depression, concentration - Hypo/Hyperthyroid symptoms: weight changes, appetite, constipation, cold intolerance, menstrual irregularities - Anaemia: fatigue, breathlessness on exertion - Diabetes: polyuria, polydipsia, infections - Chronic infection, local malignancy symptoms: FLAWS, anorexia PMH, FH- psychiatric illness, thyroid problems, autoimmune conditions- T1DM SH, DH+allergies, ICE weight changes appetite fatigue PC could be any of these symptoms, but most likely weight changes, tiredness, appetite changes, cold intolerance.

Examination *Wash hands again* General inspection: Sweaty/inappropriate clothing for weather Agitated, hyperactive, tremors, anxious Hoarse voice? (thyroid enlargement compressing recurrent laryngeal nerve) Walking aids- proximal myopathy Hands: Dry/Sweaty hands Palmar erythema Thyroid acropachy: phalangeal bone overgrowth and soft tissue swelling associated with Grave’s autoantibodies Thyroid acropachy Onycholysis Tremor Pulse (15s)- brady/tachy/irregular

Examination Eyes: Loss of outer ⅓rd of eyebrows Exophthalmos- examine eyes from front, sides and above (back) Ophthalmoplegia - H test keeping head still. - Ask if any pain/double vision before AND after H test. Lid lag- move finger downwards, upper eyelids will lag Mouth: Inspect for undescended thyroid, thyroglossal cyst or lingual goitre at back of tongue. (protrude tongue and say aah) Exophthalmos: looking for lid retraction (whether sclera visible above iris), inflammation of conjunctiva. Caused by abnormal connective tissue deposition behind eyes. Ophthalmoplegia- look for any restriction of eye movement Lid lag is associated with symp overactivity Thyroglossal cyst: birth defect- fibrous cyst formed from persistent thyroglossal duct. Lingual goitre: tumour at back of tongue formed by enlargement of embryonic remnant.

Examination Neck: Closer inspection from front AND side- goitre, thyroidectomy scars Ask patient to protrude tongue, then swallow a sip of water, while observing thyroid. Palpation - From BEHIND. - Ask about pain, warn that might be uncomfortable. - Palpate left and right thyroid lobes. - Palpating thyroid bilaterally, repeat tongue protrusion + swallowing. - Palpate cervical lymph nodes. Firm nodes near a goitre suggests malignancy Tracheal deviation- could be caused by large thyroid mass (warn discomfort) Make it obvious that you’re looking at the thyroid in particular. Thyroglossal cyst would move upwards on protruding tongue. A goitre would move upwards on swallowing, unless v large/fixed to underlying tissues by cancer. Could have diffuse tenderness in viral thyroiditis.

Examination Neck: Percussion- downwards from sternal notch. Dullness indicates retrosternal goitre. Auscultation - With bell of stethoscope, right and left thyroid lobes. - Bruit indicates abnormal vascularity (feature of Grave’s) Special tests - Pretibial myxoedema: non-pitting oedema (no indentation) - Proximal myopathy: cross arms and stand up. Proximal muscle wasting - Pemberton’s sign: raise hands above head. Facial venous congestion - Reflex (calcaneal/biceps): Hyporeflexia/Hyperreflexia Thank patient, wash hands and present findings to examiner. Proximal myopathy: Excess thyroxine stimulated degradation of muscles fibres at the motor end plates of neuromuscular junctions. Pemberton’s sign: Venous vasculature of thoracic inlet can get compressed against a large goitre when arms are raised, causing SVC obstruction resulting in a plethoric red face.

Investigations To complete my exam I would like to: Take a full Thyroid-focussed History Thyroid Function Test (TFTs: TSH, T3/fT3, T4/fT4) 12-lead ECG (Further imaging e.g radioisotope uptake/ultrasound scan) (anti-TPO autoantibodies)

TFT interpretation Check name, DOB, NHS number of patient, date of test results. Primary hypothyroidism: Secondary hypothyroidism: Hyperthyroidism: TSH↑ fT3↓ fT4↓ TSH↓or normal fT3↓ fT4↓ TSH↓ fT3↑ fT4↑

NOTE A goitre is just an enlargement of the thyroid – patient can still be euthyroid

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