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Thyroid status/ Neck Examination:
1) Introduction/consent/indications/wash hands/name & age of patient/asks patient for sites of pain before commencing:
2) General Inspection:
- With consent, assess nature of patient's voice (dysphonia)
- Assesses dress of patient (overdressed in hypothyroidism), obvious weight gain/ loss, obvious hair loss (outer 1/3 of eyebrow missing in hypothyroidism)
- From front, student inspects for: Obvious scars, goitre, tracheal deviation (repeating inspection from the side and posteriorly). Student then requests patient to protrude tongue forward (upwards moving lump thyroglossal cyst, attached to the hyoid bone), to blow out (protrusion = laryngocoele), and finally, asking patient to swallow water whilst inspecting thyroid from front (lumps adhered to thyroid, will move upwards due to attachment to thyroid cartilage)
- Assesses hands: Pallor, temperature, texture (dry/ oily) pulse rate (AF, tachycardia) and tremor (fine tremor, hence place a piece of paper on either hand extensor surfaces). Also assesses for thyroid acropachy (appear as clubbing)
- Checks for any opthalmoplegia (H sign)
- Lid lag is examined by holding patient's head still with one hand, and asking the patient to follow a vertical movement of a pen
- Proptosis is examined from above, with exopthalmos defined as sclera visible below the iris. Student also examines eyes for evidence of chemosis and visual acuity (optic nerve compression from retro-orbital inflammation)
3) Palpation:
- Position of thyroid is determined by identifying the thyroid cartilage, sliding fingers down 2cm to cricothyroid cartilage, and moving to next ring down
- From behind patient, asks for areas of tenderness: viral thyroiditis
- Student alternatively feels the lobes of the thyroid with each hand as well as the isthmus, asking patient to swallow if lumps are present. If the lump moves with lifting the skin, then this is a dermoid mass - most likely a sebaceous cyst (transillumination confirms this). The thyroid also fuses with surrounding structures if a cancer is aggressive (anaplastic)
- In the presence of a mass comment on: Site, shape, size, consistency, fluctuation, tenderness and pulsatility. Masses will either be solitary nodular, multi nodular or diffuse goitres
- Examine lymph nodes, noting size, texture and mobility, as well as tenderness. Submental, submaxillary, cervical, occipital, post auricular, pre auricular, supra-clavicular and infra-clavicular
4) Percussion:
- Retrosternal goitre presence will require percussion. This is only if lower edges of thyroid are not identified or if there are breathing and swallowing difficulties experienced
5) Auscultation:
- For thyroid bruits (increased vascularity associated with thyroid disease)
6) Further assessment:
- Pemberton's sign: Asks patient to lift arms for 1 minute (looking for plethoric face, distended neck veins and stridor) - associated with SVC obstruction due to retrosternal goitre
- Heart sounds: Checks for a flow murmur associated with hyperdynamic circulation
- Assesses for proximal myopathy in arms and legs
- Assesses for exaggerated reflexes in arms and legs
- Pretibial myxodema: Inflammation above lateral malleolus, progressing to thickened oedema of legs and feet)
- Thyroid acropachy: Clubbing & subperiosteal new bone in phalanges)
7) Thanks patient & documents findings in the notes:
Author:
Mr Adnan Darr MBCHB, BSc, MSc, MRCS
| Speciality:
Examination
| Date Added:
30/09/2011
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