Thyroid Examination - OSCE PDF

Preview

Summary

OSCE...

Description

Thyroid Examination Theory - Thyroid in anterior to trachea in neck - It is inferior to thyroid cartilage - Comprised of 2 lobes that form a H shape o Median isthmus which would connect the lobes o Isthmus superior border would be inferior to the cricoid cartilage o Isthmus inferior border overlies the first 3-4 tracheal cartilage - Thyroid gland is an endocrine gland that would secrete hormones into the bloodstream o T4 (thyroxine)  Role in the regulation of BMR including that of heart and muscles o T3 (triiodothyronine)  Similar to T4  More potent role  T3 synthesised from T4 using enzymes - Thyroid gland controlled from hypothalamus o TRH released -> stimulates pituitary to release TSH o Would be triggered when T3&T4 levels would decrease o Levels would then increase o Negative feedback to stop signalling - T3 and T4 production would depend on dietary iodine consumption o Tyrosine combined with iodine to produce DIT and MIT o DIT and MIT combined to produce T3 and T4 - If there is insufficient T3 and T4 – lead to goitre o Hypothyroidism leads to this - However – excess T3 and T4 can lead to goitre because of hyperplasia o Hyperthyroidism leads to this Indications - Patient history o Hyperthyroidism  Weight loss  Increased appetite  Increased frequency of defecation  Intolerance of heat  Sweating  Palpitations  Irritability  Nervousness  Tremor o Hypothyroidism  Weight gain  Hair loss  Coarse hair

-

 Constipation  Intolerance of cold  Hoarse, croaky voice  Dry skin  Lethargy  Carpal tunnel syndrome  Deafness Examination o Hyperthyroidism  Agitation  Fine tremor  Hot  Sweaty palms  Clubbing  Onycholysis  Tachycardia  Atrial fibrillation (irregularly irregular rhythm  Eye changes – lid lag, exophthalmos  Brisk reflexes – ankle jerk o Hypothyroidism  Lethargy  Puffy, coarse facial features  Hair loss  Loss of eyebrows  Pale waxy skin  Bradycardia  Delayed reflex relaxation – ankle jerk  Pericardial/pleural effusion

Introduction - Wash/Gel hands - Introduce yourself - Confirm patients name and DOB and check the ID wrist - GAIN CONSENT before continuing - Explain what you want to do - GAIN INFORMED CONSENT - Consider an appropriate chaperone - Adequate exposure of the patient whilst maintaining dignity - Position the patient appropriately General Inspection - Patient should be in an upright position - Appearance o Anxious (hypo) o Flushed (hyper) o Thin (hyper) o Thinning hair (hypo)

-

-

-

-

Hands and nails o Nail changes – clubbing, koilonychias o Clammy palms o Tremor  Place paper on back of patients hands and not any tremor o Check pulse o Check BP Eyes o Exophlathmos  Stand to either side of the patient – near eyes  Look down on them from above their head  Eyes protrude – hyper (grave’s disease)  Would have associated symptoms – tachycardia and sweating o Lid lag  Secondary to lid retraction  Lid retraction – upward displacement of upper eyelid  Is called Graefe’s sign – hyperthyroidism  Due to the muscle bulking within orbit o Pushes eyeball forward  Also, because increased thyroid hormone – sympathetic activity on the levator palpebrae superioris  Test for this by  Place finger horizontally 1m away from patient  Drop finger downwards  Ask patient to keep head still and follow finger with their eyes  Can observe the lid lag Tongue o Stick patients tongue out  Thyroglossal cyst would move upwards Legs o Pretibial myxoedema  Waxy orange appearance of skin  Anterior aspect of lower legs

Specific inspection - “Have you got any pain in your neck” - Patient would be seated - Observe any swelling/goitre o Bilateral o Unilateral - Look from the front - Look from both sides - If there is a goitre o Ask patient to take sip of water and hold it in mouth  Swallow as you look from front  Swallow as look from side

o Thyroid issue would rise and fall with swallowing  Due to pharyngeal muscle contraction o If static – not thyroid Palpation - Stand behind patient o Warn patient you are doing this - Apply gentle pressure with finger pulps o One hand at a time o One hand for one lobe - Start at the centre and move outwards - Assess for o Size  Graves – one nodule  Multinodular goitre – multiple nodules o Shape o Surface  Graves – sof  Multinodular goitre - firm o Consistency o Edge o Fluctuance o Pulsation - Ask patient to swallow whilst palpating o Can feel upward movement if there is thyroid enlargement o Repeated because can be missed on inspection  If thyroid is not as enlarged Palpation – lymph nodes - Deep cervical - Supra-clavicular Percussion - Percuss over the manubrium and upper sternum o Thyroid can enlarge inferiorly - Normal – normal-resonant - Enlarged thyroid – dull Auscultate - Auscultate over each lobe whilst patient would hold breath o Each lobe at a time - Listen for bruits Ankle reflex - Hyperthyroidism – brisk reflex - Patient seated

-

Place hand on the balls of foot Passively dorsiflex ankle – pull towards you Strike your fingers Feel for plantarflexion

Recording findings - Document enlarged thyroid o Position  Unilateral  Bilateral  Central o Size  Length  Breadth o Consistency  Nodular  Granular  Smooth  Firm...