Endocrinology/Misc

Question 1

Intro to thyroid examination?

Answer 1

Wash hands, introduce myself, confirm patient ID- hoarse voice= hypothyroidism, explain and consent, position- on chair so you can walk around all sides

Question 2

What to inspect in thyroid exam?

Answer 2

General appearance- build, clothing inappropriate for given temperature, restlessness, confusion, hair/ skin quality
Both sides of hands, tremor, radial pulse, forearm, eyes, the thyroid

Question 3

Look for what in hands?

Answer 3

Dry skin= hypothyroidism, brittle nails= hypothyroidism, increased sweating/ temp= hyperthyroid, palmar erythema= hyperthyroid, onycholysis- hyperthyroid, thyroid acropachy- Graves’ disease
Tremor= hyperthyroid- hands outstretched and pronated, paper across back of hands and observe for quivering
Bradycardia- hypothyroid, tachy= hyperthyroid, AF= hyperthyroid
Muscle wasting= hyperthyroid

Question 4

How to inspect eyes?

Answer 4

From front, side and above- exophthalmos= anterior displacement, may lead to inability to close lids properly which may cause sight-threatening exposure keratopathy
Chemosis(conjunctival oedema,) conjunctival inspection(bloodshot)+ periorbital/ lid oedema
Lid retraction- sclera visible above cornea–> all types of hyperthyroid
Lid lag- follow finger from high downwards, delayed= hyperthyroid
Move finger in H- observe restriction of movements and ask patient to report any diplopia/ pain
Visual acuity and fundoscopy- proptosis may stretch optic nerve, optic disc appears normal but may be atrophic in long-standing cases with irreversible vision loss

Question 5

How to inspect the thyroid?

Answer 5

Inspect for masses- skin changes/ scars from previous thryoidectomy, normal= should not be visible
Water test- observe while they swallow, thyroid masses and thyroglossal cysts move WITH swallowing, lymph nodes will move very little
Tongue test- protrude tongue, masses/ lymph nodes will NOT move, cysts will move upwards noticeably
Back of tongue for lingual thyroid

Question 6

What to palpate in thyroid exam? See what for trachea?

Answer 6

Trachea, thyroid, lymph nodes

To see if deviated–> large goitre

Question 7

How to palpate the thyroid?

Answer 7

Stand behind and ask them to slightly flex their neck, place hands on either side of neck and ask if pain before palpating
Place 3 middle fingers of each along midline of neck below chin and locate upper edge of thyroid cartilage, move inferiorly until cricoid cartilage is reached
First two rings= below cricoid cartilage and isthmus overlies this area
Palpate each lobe in turn using pads of fingers, moving laterally from isthmus

Question 8

What to assess in thyroid palpation?

Answer 8

Size and site
Masses- hard/ soft
Consistency- smooth/ nodular, single/multiple
Mobility- fixed/ mobile
Position- can you feel above the mass, below in suprasternal notch- not, may be retrosternal goitre
Water test- asymmetrical elevation may suggest unilateral thyroid mass
Tongue test- if thyroglossal cyst, it will rise

Question 9

What lymph nodes to palpate?

Answer 9

Supraclavicular, anterior cervical chain, posterior cervical chain, submental nodes

Question 10

3 other things for thyroid exam? Percuss downwards from where?

Answer 10

Percussion, auscultation, special tests

Sternal notch- retrosternal dullness may indicate retrosternal extension of goitre

Question 11

How to auscultate for bruit?

Answer 11

Ask patient to hold breath, bruit= increased vascularity secondary to Graves’ disease

Question 12

3 special tests for thyroid?

Answer 12

Reflexes: hyporeflexia= hypothyroid, biceps/ ankle reflex, normally brisk but slow to return to resting state in hypothyroid
Pretibial myxoedema- Graves’ disease
Proximal myopathy- stand from sitting with arms crossed, inability= proximal muscle wasting–> hyperthyroid

Question 13

Further assessments for thyroid?

Answer 13

Thyroid function tests, ECG if irregular pulse, further imaging- ultrasound scan

Question 14

Intro to diabetic foot exam?

Answer 14

Wash hands, introduce myself, confirm patient, explain, consent and expose: general inspection, feel some areas of your feet and testing your sensation
Chaperone, any pain in ankles/ feet

Question 15

Inspect what 4 things?

Answer 15

Bedside, skin, feet, gait

Shoes for signs of uneven wear, foreign objects

Question 16

What things to look for on skin?

Answer 16

Trophic changes; hairlessness, pallor, decreased sweating, dry cracked skin
Rubor at pressure points
Skin ulceration
Diabetic dermopathy- brown macules over skins
Infection; cellulitis(erythema, swelling), gangrene
Web-spaces of every toe; cracked, infected, ulcers, maceration (wrinkles)
Toenails; dystrophic, in growing, nail and skin meeting base of foot, fungal infections
Feet: deformities (Charcot arthropathy,) intrinsic muscle wasting(clawed, hammer toes)
Flat foot/ high arch
Gait: normal heel strike/ toe off gait
Normal height of each step- high-stepping in foot drop, smooth and symmetrical?

Question 17

Palpate what in diabetic foot?

Answer 17

Bones and joints of ankle/ foot for swelling and tenderness, watch patient’s face for discomfort

Question 18

What vascular things to inspect in diabetic foot?

Answer 18

Temperature with back of hands comparing shins to feet bilaterally- low= poor peripheral perfusion, high temp= cellulitis/ DVT
Capillary refill
Pulses starting distally- dorsalis pedis, posterior tibial, popliteal, femoral- absence may indicate PVD

Question 19

What neurological things to inspect in diabetic foot?

Answer 19

Light touch with cotton wool
Pressure- sternum for comparison, on pulp of 1st, 3rd, 5th metatarsal heads so bends slightly, hold for 1-2 seconds
Pin prick, temperature
Proprioception- hold distal phalanx by its sides, demonstrate while they watch, then closed
Move to more proximal joint- big toe, ankle, knee, hip
Vibration- on distal phalanx, feel it buzzing then if stops, impaired–> more proximal= proximal phalanx, ankle, knee, hip

Question 20

Further assessments diabetic foot?

Answer 20

Cervical spine and elbow joints, full neurological and vascular examination of patient’s upper limbs

Question 21

Ask about what in thyroid history?

Answer 21

Symptoms arising from the swelling
The thyroid status hyper vs hypothyroidism
Associated symptoms
Relevant medical hx

Question 22

Symptoms arising from the swelling?

Answer 22

Duration and change in size, cosmetic symptoms, discomfort during swallowing/ dysphagia- oesophageal compression, dyspnoea(tracheal compression), hoarseness- recurrent laryngeal nerve paralysis secondary to malignant infiltration

Question 23

Also ask about what thyroid?

Answer 23

Eye symptoms e.g. protruding/ staring, difficulty closing eyelid, double vision and pain in eye
Previous operation on the thyroid gland
Previous/ current medication e.g. anti-thyroid drug, thyroxin, iodine containing medications
Radio-iodine therapy for previous Grave’s disease

Question 24

What stages of examining an ulcer?

Answer 24

Look, feel, move, special tests and examination of the regional lymphatic drainage

Question 25

Look for what of an ulcer?

Answer 25

Number- multiple in arterial disease
Site
Size- depth in mm
Shape- varicose= vertically oval, malignant= irregular in shape
Margin- junction between normal and abnormal skin
Edge- tissue between the margin and the floor of the ulcer e.g. sloping, punched out
Floor- healthy/ unhealthy tissue, slough, scab, fat, muscle, tendon, periosteum/ bone
Discharge- quantity, consistency, colour, composition, odour e.g. serous, sanguineous (blood stained,) purulent/ green (pseudomonas colonisation/ infection)
Surrounding skin- hyperpigmentation, oedema, erythema, stretch marks, and wrinkling
Whole limb- venous and arterial insufficiency and neurological disease, muscle wasting

Question 26

Feel for what in an ulcer?

Answer 26

Tenderness
Temperature of ulcer and surrounding skin using back of hand
Palpate edge of ulcer for induration= feature of chronic benign ulcers and of malignant ulcers
Whether the ulcer bleeds on gentle touch/ not, often feature of malignancy

Question 27

Moving ulcer? Also examine what?

Answer 27

Gently attempt to move the base of the ulcer using thumb and forefinger, fixation–> deeper structures may be suggestive of malignancy

Regional lymphatic drainage

Question 28

Special tests for ulcer?

Answer 28

Peripheral pulses
Light-touch and pressure sensation
Nearby joints if evidence of bony involvement

Question 29

Intro for breast examination?

Answer 29

Wash hands, intro, chaperone, expose, any pain?

Position seated on edge of couch and with arms by their sides

Question 30

Inspect for what breast exam?

Answer 30

Symmetry- abnormalities in contours e.g. tethering/ dimpling
Visible masses
Erythema of skin +/- abnormal scaling (hyperkeratosis and desquamation) of nipple and areolar skin
Nipple retraction- duration? May be normal
Hands behind head and push shoulders back- appearance/ accentuation of skin tethering
Hands on hip and push inwards- fixes pectoralis major and may accentuate lumps tethered to it

Question 31

Position for palpation? How to palpate?

Answer 31

Lie at 45 degrees, may have arm above head
Mentally divide breast into 4 quadrants, plus axillary tail and nipple
Palpate each quadrant, axillary tail and nipple using pads of index, middle and ring fingers, increase pressure to examine subcut tissue, mid-level and adjacent to underlying chest wall
Palpate axillary lymph nodes whilst supporting patients arm with free hand, using rolling action against posterior, medial, anterior and apical boundaries of axilla
Nipple- inspect for discharge
Supraclavicular fossa for lymphadenopathy
Abdomen for hepatomegaly if malignancy suspected/ history of malignant disease, vertebral spinous processes for tenderness