Orientation Week Flashcards
Describe professionalism
Everything that doesn’t fit into the technical/non-technical skills of being a doctor OR the rules and regulations of your job.
What the patient will remember about you - appearance, actions, behaviour (even when no one’s watching), doing the right thing for the patient.
Not just about NOT doing the wrong thing, it’s about doing good things.
Describe the importance of professionalism
It’s what the patient will remember about you.
Main cause of trouble with the GMC.
Describe the steps of a breast examination
Introduction
- wash hands
- introduce yourself
- confrim patient details
- explain examination
- gain consent
- ask about concerns/pains
- reassure that if in pain or uncomfortable exam can be adjusted or stopped
- ensure a female chaperone is present
- allow patient to undress
Patient Preparation
- Expose patient
Inspection
- Four positions to work through: sitting with hands on lap, sitting with hands behind head pushing elbows out , hands pressing into hips (contraction of pectoralis major - if masses move with chest muscle it suggests tethering to underlying tissue, this maneouvre may also accenuate puckering), leaning forward (will exacerbate dimpling, asymmetry, puckering)
- Look for aysymmetry, swelling, masses, skin changes, nipple changes, surgical scars
Nipple abnormalities
-nipple inversion is a normal finding in a significant proportion of women (e.g. congenital or weight-loss associated nipple inversion).
-however, if nipple inversion develops without a clear precipitant, the possibility of underlying pathology should be considered.
-possible pathological causes of nipple inversion include breast cancer, breast abscess, mammary duct ectasia and mastitis.
- nipple discharge is benign is most cases (e.g. pregnancy, breast-feeding) however less commonly it can be associated with mastitis or underlying breast cancer (rare).
Skin changes associated with breast pathology
- scaling of the nipple and/or areola associated with erythema and pruritis are typical features of Paget’s disease of the breast (see the example image). Paget’s disease is associated with underlying in-situ or invasive carcinoma of the breast.
-erythema of the breast tissue has a wide range of causes including infection (e.g. mastitis or breast abscess), trauma (e.g. fat necrosis) and underlying breast cancer.
- puckering of breast tissue is typically associated with invasion of the suspensory ligaments of the breast by an underlying malignancy that results in ligamentous contraction which draws the skin inwards.
- peau d’orange (dimpling of the skin resembling an orange peel) occurs due to cutaenous lymphatic oedema. The dimples represent tethering of the swollen skin to hair follicles and sweat glands. Peau d’orange is typically associated with inflammatory breast cancer.
Breast Palpation
- get patient to lie down with bed at 45 degrees
- ask patient to put the same hand as the breast you are palpating behind their head
- start on the normal side
- palpating using the flats of three fingers, pushing the fingers into the tissue and doing circular motions
- palpate in a zig-zag pattern and palpating circularly around the nipple
- ensuring to palpate the axillary tail
- note any masses or areas of tenderness
- ask patient to squeeze nipple between their thumb and index finger to check for discharge (assess colour, consistency and volume)
Nipple discharge
- milky discharge: normal during pregnancy and when breastfeeding (bilateral). Galactorrhoea (nonpuerperal lactation) is pathological and caused by the presence of a prolactinoma.
- purulent discharge: thick yellow, green or brown discharge with an offensive smell. Possible causes include mastitis and central breast abscess.
- watery and bloody discharge: several possible causes however ductal carcinoma in situ is the most important diagnosis to consider.
- repeat on the opposite breast with the corresponding hand behind the head
- if a mass is found palpate it well and describe its size, borders, location, consistency (firm etc.) mobility (tethered, mobile etc). - assess this by asking the patient to tense their chest muscles (if it moves witht he chest it is tethered to the underlying tissue), fluctance (do the sides bulge outwards when squeezed like a cyst), overlying skin changes)
Elevate the breast
- if necessary, lift the breast with your hand to inspect for evidence of pathology not visible during the initial inspection (e.g. dimpling, skin changes).
Lymph Node Palpation
- start on normal side again
- take weight of patients arm
- examine the size consistency and fixation of the glands
- repeat on the other side
- feel infraclavicular, supraclavicular, cervical, parasternal lymph nodes
Conclusion
- thank patient
- wash hands
- allow them to get redresses
Summary
- note all findings (inspection of each side and then palapation of each breast, also include any lymph node abnormalities)
- further examinations? = imaging (ultrasound or mammogram), biopsy/fine needle aspiration of any masses, further lymph node investigation
https://geekymedics.com/breast-examination-osce-guide/
Describe the steps of a thyroid examination
Introduction
- wash hands
- introduce yourself
- confrim patient details
- explain examination
- gain consent
- are they in any pain?
- reassure that if in any discomfort or pain the examination can be altered/stopped
Prepare Patient
- ensure patient is sitting comfortably before starting the examination
- adequately expose neck and upper sternum
General Inspection
- does the patient appear agitated, anxious, or fidgety (signs of hyperthyroidism)
- is the patient sweaty (hyperthyroidism)/
- does the skin appear dry (hypothroidism)
- are they overweight (hypothyroidism)
- are they underweight (hyperthroidism)
- clothing? hyperthyroidism = heat intolerance (wear cooler clothing), cold intolerance = hypothyroidism (warmer clothing)
- hoarse voice (can be caused by compression of the larynx due to thyroid malignancy
- mobility aids? proximal myopathy (hyperthyroidism) can result in the need for walking aids
Inspection of Hands
- ask patient to hold hands out in front of them and splay fingers
- thyroid acropachy? (red swollen digits with clubbing) - indicitive of Graves’ Disease
- peripheral tremor? (a piece of paper may make the tremor more visible) - hyperthroidism
- onycholysis (painless detachment of the nail from the nail bed) associated with hyperthyroidism
- ask patient to turn hands over
- dry skin? - hypothyroidism
- palamar erythema? - hyperthyroidism?
- sweaty plams - hyperthyroidism
- feel radial pulse (tachycardic? (hyperthyroidism), bradycardic? (hypothyroidism), irregular rhythm? (atrial fibrillation - associated with hyperthyroidism)
Inspection of Face
- sweating? - hyperthyroidism
- dry skin? - hypothyroidism
- loss of outer 1/3 of the eyebrow? - hypothyroidism
Inspection of Eyes
- inspect for exophthalmos - look at eyes from the front, both sides, and above (patient may need to look slightly up for this and you should stand behind the patient (bulging eyes) by asking the patient to look at a spot on the wall behind you - Graves’ Disease
- look for lid retraction (Graves’ Disease or other thyrotoxic states) - patient still looking at a point on the wall (sclera visible above the iris)
- inflammation of the eye (can be caused by symptoms of Graves’ Disease i.e., exophthalmos and lid retraction
- H test (ask patient to follow your finger with their eyes only which you will move in an H shape) - ask them to let you know if they experience any pain or discomfort during - observe for restriction of eye movements
- restricted movements or pain during eye movement can be indicitive of Graves’ Disease
- assess for lid lag - ask patient to follow your finger with their eyes only as you move it up then down)
Inspection of Neck
- ask patient to sit relaxed
- look for skin changes such as erythema (hyperthyroidism), scars (thyroidectomy, masses (goitre (hypothyroidism) or lymph nodes)
- ask patient to drink some water - observe for movement of any masses on swallowing
- ask patient to protrude their tongue, again assessing for movement of masses
- no movement = thyroid gland mass or lymph node
- upward movement = thyroglossal cyst
Thyroid Palpation
- stand behind pateint to palpate
- begin palapation at the thyroid cartilage (Adam’s apple)
- move downwards to the cricoid cartilage
- below the cricoid cartilage is the isthmus of the thyroid gland
- palpate the isthmus and then each lobe individually
- assess the following characteristics of the thyroid (size, symmetry, consistency, masses, palpable thrill (Graves’ Disease (increased vascularisation))
- ask pateint to protrude tongue - thyroglossal cyst will rise
- ask patient to swallow some water and assess the symmetry of the thyroid lobe elevation - asymmetry may suggest a unilateral thyroid mass
- feel local lymph nodes (submental,
submandibular,
pre-auricular,
post-auricular,
superficial cervical,
deep cervical,
posterior cervical,
supraclavicular) for lymphadenopathy (swellign fo the lymph nodes) by pressing and rollign them with the pads of 3 fingers - associated with thyroid malignancy
- if a mass is found assess position, shape, consistency, mobility
- assess for tracheal deviation (i.e., due to large goitre) - inform patient this may be uncomfortable
Percussion
- percuss the sternum - may sound dull if a mass is present i.e., large goitre extending downwards
Thyroid Auscultation
- listen to each lobe of the thyroid, while patient holds their breath, to listen for a bruit (caused due to increased vascularisation secondary to Graves’ Disease/hyperthyroidism)
Reflexes
- hyporeflexia associated with hypothyroidism
- ask patient to relax arms on lap with palms facing upwards
- test biceps reflexes on both arms
Misc
- inspect for pre-tibial myxodema (localised lesions in the skin caused by deposition of hyaluronic acid) by asking patient to expose their shins - indiciatve of Graves’ Disease
- assess for proximal myopathy (symmetrical weakness of the proximal part of the upper and/or lower lims) by asking patient to stand from sitting with arms crossed - a patient with hyperthyroidism would have proximal myopathy and be unable to do this test
Conclusion
- thank patient
- wash hands
- summarise findings (anythign found on inspection and then no other peripheral stigmata of thyroid disease, any evidence of thyroid eye disease?, any goitre?
- further examinations? TFTs (TSH and T4) and imaging
https: //geekymedics.com/thyroid-status-examination/
Describe the aetiology of atherosclerotic disease
Characterised by
-calcification
- plaque formation
- arterial wall thickening and elasticity loss
“hardening of the arteries”
State the risk factors for atherosclerotic disease
Non-Modifiable
- Increasing age
- Sex (male)
- Family history
Modifiable
- Cigarette smoking
- Diabetes
- Hyperlipidaemia
- Hypertension
- Obesity
- Pro-thrombotic tendencies
State signs and symptoms of peripheral arterial disease
- hair loss on the legs and feet
- numbness or weakness in the legs
- brittle, slow growing toenails (often deformed and have ridges)
- uclers
- colouration changes i.e., dark red, pale, or blue
- shiny skin
- erectile dysfunction in men
- muscle wasting in the thighs
- claudication (patients complain of pain in the muscles of the leg on walking and this is relieved by rest)
Discuss treatment options for revascularisation
Open Surgery
•Endarterectomy
- Removes the intima and therefore the plaque
- The artery is then closed up with a graft (either the patient’s own great saphenous vein or a bovine pericardial graft – preferably the patient’s own tissue as the post-surgery risk is lower
Bypass Graft
- Essentially just plumbing – starts before the blockage and ends after the blockage
- Uses either the patient’s own great saphenous vein or a PTFE graft
- Preferably the patient’s great saphenous vein as if infection occurs it is very difficult to handle in a PTFE graft as the graft develops a biofilm in response to infection
Endovascular
•Plain Balloon Angioplasty
- Compresses the plaque to widen the lumen – there may need to be multiple balloon angioplasties or they may not work at all as the plaque can spring back to its original position
•Balloon Angioplasty with Stent
- Same as a plain balloon angioplasy but they deploy a stent to keep the vessel open
- Stents often contain metal – they are a huge thrombosis risk and therefore not often offered to people at increased risk, such as smokers, as the risk of the procedure outweighs the benefits
Discuss the significance of an Abdominal Aortic Aneurysm (AAA)
A dilatation of the abdominal aorta, usually arising below the level of the renal arteries.
Aneurysms are usually asymptomatic and are picked up incidentally although occasionally a patient will be aware of a pulsatile abdominal mass. A national screening programme for AAA has been instituted. Aneurysms are much more common in men and so males aged 65 are invited to attend for an abdominal ultrasound to visualise the aorta.
High risk of rupture which can cause life-threatening bleeding
Ruptured AAA is associated with a triad of hypotension, back pain, and a pulsatile epigastric mass
Discuss the treatment options for a AAA
Aneurysms which are less than 5.5 cm in diameter can safely be managed conservatively but they should be monitored on a regular basis as they tend to grow slowly. Any risk factors for atherosclerotic disease and these should be addressed
Once they reach 5.5 cm in AP diameter treatment should be considered as the risk of rupture increases. Large aneurysms may cause acute symptoms in the form of back or loin pain or collapse due to hypovolaemia. This is a sign that the aneurysm has, or is about to rupture and is a surgical emergency.
Abdominal aortic aneurysms can be repaired either by open surgical techniques where the aneurysmal artery is replaced with a synthetic graft, or by endovascular techniques where, under X-ray control, the aneurysm is excluded by placing a covered stent graft in the aortic lumen (EVAR – endovascular aneurysm repair).
Open aneursym repair
- Vessel opened and a graft inserted
- Graft can have ‘limbs’ to accommodate for any opening in the endogenous AA for other vessels
Endovascular aneurysm repair (EVAR)
- Guideline is inserted from the groin area on both sides and a device implanted (device has limbs)
- Anatomy dependent as the top area must be tubular in shape to support the device
- Has a higher risk of leakage
Discuss claudication
Intermittent claudication
- Seen in less severe causes of peripheral vascular disease
- Where patients complain of pain in the muscles of the leg on walking and this is relieved by rest
- Patients often complain of cramping pain affecting the calf muscles and this usually indicates atherosclerotic disease in the superficial femoral artery.
- Less commonly, they can complain of pain affecting the buttock and thigh and this usually indicates more proximal disease affecting the aorto-iliac segment.
The severity of the disease is indicated by the walking distance, the more severe the disease the shorter the distance the patient is able to walk. This will also be shorter if the patient hurries, goes up an incline or climbs stairs.
The symptoms may remain stable for months or years and a sudden deterioration usually indicates a further occlusive episode. This is often followed by a period of gradual improvement due to opening up of collateral vessels. These symptoms do not occur at rest or on standing and the differential diagnosis includes arthritis of the hip or knee or nerve root compression secondary to spinal stenosis.
If the disease process progresses the symptoms will worsen and the walking distance will reduce.
Claudication in itself is a relatively benign symptom and can usually be managed conservatively. It should, however, be viewed as a marker for generalized atherosclerotic disease.
Discuss Chronic Limb-Threatening Ischaemia
In very severe cases the ischaemia will progress to a situation where the patient experiences symptoms at rest. This is termed chronic limb threatening ischaemia(CLTI) and is characterized by severe pain across the metatarsal heads or in the toes (at the extremity of the limb), often occurring first at night when the patient is in bed. The pain often wakes the patient and typically relief is obtained by dangling the foot over the side of the bed or getting up and standing. Some patients will sleep upright in a chair.
Revascularisation or amputation is needed to obtain long-term relief. Rest pain is always accompanied by severe claudication (<50m) if the patient is able to walk. In the most severe cases, there is insufficient blood getting down to the tissues even at rest and so trophic changes occur with ulceration or gangrene developing.
Chronic limb threatening ischaemia is therefore characterised by the triad of rest pain, ulceration and /or gangrene.
It is unusual for most patients with PVD to deteriorate to this extent. Less than 10% of patients with intermittent claudication will go on to develop critical limb ischaemia.
A history looking for symptoms of coronary and cerebrovascular disease should be sought.
Any risk factors for atherosclerotic disease should be identified and, where possible, corrected
All patients should be on an anti-platelet agent and a statin.
When patients have critical ischaemia attempted revascularization is indicated. This may be by endovascular (angioplasty +/- stenting) or open surgery (bypass) depending on the nature of the occlusive lesion. If this is unsuccessful or is not possible major amputation is usually required.
Describe a peripheral pulse
Each contraction of left ventricle results in volume of blood ejected into arterial tree.This systolic heart contraction results in a pressure wave
Pulse represents palpable arterial pulsation after each heartbeat and is felt where an artery can be compressed against bone
Consider rate, rhythm, volume and the feeling of the arterial wall
Name and state the positions of the main peripheral pulses
Carotid - between the larynx and the anterior border of the sternocleidomastoid muscle.
Brachial - palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus in the cubital fossa
Radial - on thumb side just below the wrist area
Ulnar - on the pinky side just below the wrist area
Femoral - mid inguinal point – halfway between anterior superior iliac spine and pubic symphysis
Popliteal - inferior region of the popliteal fossa, found by holding the bent knee
Dorsalis pedis - over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones.
Posterior tibial - posterior to the medial malleolus of the tibia.
Describe Allen’s Test
Occluding both the radial and ulnar arteries until the hand blanches and then releasing one artery (typically the ulnar artery (as the test is often used to assess the suitability of the radial artery for procedures and you don’t want to risk damage to the radial artery if the ulnar artery is unsuitable) and assessing if the hand pinks up again
Describe Buerger’s Test
Buerger’s test is used in an assessment of arterial sufficiency. With the patient lying down you raise the leg until the skin pallors, the patient then dangles their leg over the side of the exam bed. In a normla limb, pallor will not occur. In an iscahemic limb, pallor will occur witht he leg raised and then rubor when the leg is dangled over the edge of the bed.
The vascular/Buerger’s angle, is the angle to which the leg has to be raised before it becomes pale, whilst lying down. In a limb with a normal circulation the toes and sole of the foot, stay pink, even when the limb is raised by 90 degrees. In an ischaemic leg, elevation to 15 degrees or 30 degrees for 30 to 60 seconds may cause pallor. (This part of the test checks for elevation pallor.) A vascular angle of less than 20 degrees indicates severe ischaemia
From a sitting position, in normal circulation, the foot will quickly return to a pink colour. Where there is peripheral artery disease the leg will revert to the pink colour more slowly than normal and also pass through the normal pinkness to a red-range colouring (rubor - redness) often known as sunset foot. This is due to the dilatation of the arterioles in an attempt to rid the metabolic waste that has built up in a reactive hyperaemia. Finally the foot will return to its normal colour. This part of the test is known as a check for rubor of dependency.
Describe the basic anatomy of the breast
Position
- Anterior chest wall between mid-axillary line and sternal border
- Between ribs 2 and 6
- 2/3rd lies on pec major and 1/3rd on serratus anterior
- Tail of breast tissue extends into axilla
Structure
- 15-20 lobules per breast separated by fibrous ligaments of Cooperconnected by a ductal system.
- Ducts converge at lactiferous sinus, just below nipple
- Breast tissue is covered by a layer of subcutaneous fat.
Arterial supply
- Medially via internal thoracic (mammary) artery –via perforating anterior branches
- Laterally via axillary artery branches (Lateral thoracic artery, Pectorial branch of acromio-clavicular artery, Sub-scapular artery)
- Intercostal arteries –Lateral perforating branches
Venous drainage
- Corresponding veins
Lymphatic drainage
–Axillary nodes – drain 75% of the breast (Nodes described by specific level (Level 1-inferior to pec minor, Level 2- posterior to pec minor, Level 3- superior to pec minor))
–Internal thoracic/ mammary nodes -account for approx. 25% drainage
CHECK BREAST EXAM POWERPOINT FOR RELATED IMAGES
Describe a targeted breast history
Breast symptoms: PLANS
- Pain (mastalgia) - cyclical or non-cyclical
- Lump(s) – how long, change over time
- Asymmetry of breast
- Nipple problems - inversion, crusting, discharge – colour, frequency
- Skin changes – tethering, erythema, peau d’orange
May be asymptomatic: family history, screening
Also ask about previous contact with breast services, previous breast surgeries, screening attendance.
List key risk factors for the development of breast cancer
–Age
–Sex
–Lifestyle: smoking, alcohol
–Hormone replacement therapy and COCP
–Early menarche, late menopause, nulliparity
–Breastfeeding protective
–Family history of breast and ovarian cancer
–1st or 2nd degree relatives
–Genetic prediliction BRCA1/2, Li Fraumeni
Describe the components of triple assessment
•Clinical examination
–By a surgeon or trained HCP
–Systematic exam of both breasts, axilla, supraclavicular nodes
•Imaging
–Age <35yrs Ultrasound
~35yrs depends on presentation
–>35 yrs two view Mammography +/- Ultrasound
•Biopsy
– Fine needle aspiration - cytology
–Core biopsy or vacuum assisted biopsy - histology
–
Followed by MDT discussion if appropriate
Describe how to discuss a lump
–Site (including side if necessary i.e., a breast lump)
–Size in two perpendicular planes
–Edges- smooth or craggy/irregular
–Consistency - hard, firm, fluctuant (the mass bulges when squeezed i.e., a cyst)
–Discrete or diffuse
–Mobility
–Tethering/fixity
–Node involvement
- Overlying skin changes
THIS SYSTAM CAN BE USED TO DESCRIBE ANY LUMP
Describe skin abnormalities that may be seen during a breat examination
Scars: these may indicate previous breast surgery such as lumpectomy (small scar) or mastectomy (large diagonal scar).
Asymmetry: this can be helpful in identifying abnormalities via comparison, however, it should be noted that breast asymmetry is a normal feature in most women.
Masses: note any visible lumps that will require further assessment.
Nipple abnormalities: these can include nipple inversion and discharge.
Skin changes: including scaling, erythema, puckering and peau d’orange.
Discuss the possible underlying cause/pathology of skin and nipple changes which may be seen during a breast exam
Scaling of the nipple and/or areola associated with erythema and pruritis are typical features of Paget’s disease of the breast. Paget’s disease is associated with underlying in-situ or invasive carcinoma of the breast.
Erythema of the breast tissue has a wide range of causes including infection (e.g. mastitis or breast abscess), trauma (e.g. fat necrosis) and underlying breast cancer.
Puckering of breast tissue is typically associated with invasion of the suspensory ligaments of the breast by an underlying malignancy that results in ligamentous contraction which draws the skin inwards.
Peau d’orange (dimpling of the skin resembling an orange peel) occurs due to cutaenous lymphatic oedema. The dimples represent tethering of the swollen skin to hair follicles and sweat glands. Peau d’orange is typically associated with inflammatory breast cancer.
Nipple inversion is a normal finding in a significant proportion of women (e.g. congenital or weight-loss associated nipple inversion). However, if nipple inversion develops without a clear precipitant, the possibility of underlying pathology should be considered. Possible pathological causes of nipple inversion include breast cancer, breast abscess, mammary duct ectasia and mastitis.
Nipple discharge is benign is most cases (e.g. pregnancy, breast-feeding) however less commonly it can be associated with mastitis or underlying breast cancer (rare).
State how you would describe nipple discharge if seen during a breast exam and discuss causes/pathologies of different types of discharge
Assess the characteristics of the discharge:
- Colour (e.g. blood-stained, green, yellow)
- Consistency (e.g. thick, watery)
- Volume
Milky discharge: normal during pregnancy and when breastfeeding (bilateral). Galactorrhoea (nonpuerperal lactation) is pathological and caused by the presence of a prolactinoma.
Purulent discharge: thick yellow, green or brown discharge with an offensive smell. Possible causes include mastitis and central breast abscess.
Watery and bloody discharge: several possible causes however ductal carcinoma in situ is the most important diagnosis to consider.
Briefly describe the anatomy of the thyroid (clinically relevant anatomy)
Thyroid has left and right lobe connected by central isthmus
Usually found just below thyroid cartilage and moves on swallowing.
Occasionally can be found along thyroglossal duct and may move on protrusion of tongue
Can enlarge into superior mediastinum or retrosternal space
Rarely, significant enlargement can cause tracheal compression
Blood supply
- superior thyroid artery (branch of the external carotid artery)
- inferior thyroid artery (branch of the thryocervical trunk)
- thyroid ima artery (an anatomical variant with varaible origin and not always present)
Venous drainage
- superior thyroid vein (drains into the internal jugular vein)
- middle thyroid vein (drains into the internal jugular vein)
- inferior thyroid vein (drains into the brachiocephalic vein)
- the three thyroid veins form a venous plexus around the thyroid gland
Lymphatic drainage
- paratracheal nodes
- deep cervical nodes
State the signs for hyper- and hypo- thyroidism
Hypo-
- weight gain/overweight
- low mood
- cold intolerance (dress in warmer clothes than necessary)
- bradycardia
- dry skin
- loss of outer 1/3 of eyebrow
- hyporeflexia
Hyper-
- weight loss/skinny
- anxiety/hyperactive behaviours
- heat intolerance (dressing in cooler clothes than needed)
- use of mobility aids (due to proximal myopathy)
- onycholisis (painless detachment of the nail from the nail bed
- palmar erythema
- erythema
- peripheral tremor (due overactivity of the sympathetic nervous system (which supplies the thyroid gland))
- tachycardia
- atrial fibrillation
- excess sweating
Discuss the significance of a hoarse voice with reference to a thyroid exam
Hoarse voice: caused by compression of the larynx due to thyroid gland enlargement, e.g., thyroid malignancy
State signs indicitve of Graves’ Disease
- Chemosis (conjunctival oedema causing red eyes)
- Proptosis/ exophthalmos (forward bulging of eyes)
- Opthalmoplegia (weakness of eye muscle/s)
- Thyroid acropatchy (similar in appearance to finger clubbing but caused by periosteal phalangeal bone overgrowth) - very rare
- Pretibial myxoedema (a waxy, discoloured induration of the skin on the anterior aspect of the lower legs) - rare
- Upper eyelid retraction
- Lid lag
- Palpable thrill (due to increased vascularity)
- Proximal myopathy (a potential complication of both multinodular goitre and Graves’ disease - patients develop wasting of their proximal musculature causing difficulties in tasks such as standing from a sitting position)
- Bruit on auscultation (due to increased vascularity)
Discuss the clinical relevance of the mobility of the thyroid and/or a thyroid mass on swallowing
Ask the patient to swallow some water and observe the movement of the mass:
- Thyroid gland masses (e.g. a goitre) and thyroglossal cysts typically move upwards with swallowing.
- Lymph nodes will typically move very little with swallowing.
- An invasive thyroid malignancy may not move with swallowing if tethered to surrounding tissue
- The lobes of the thyroid gland usually rises symmetricaly (asymmetrical elevation may suggest a unilateral thyroid mass).
Describe a thyroglossal cyst
Thyroglossal cysts are the most common congenital abnormality of the neck and arise as a result of the persistence of the thyroglossal duct.
The thyroglossal duct is the tract by which the thyroid gland descends during embryological development to its final position in the front of the neck.
The tongue is attached to the thyroglossal duct, which is why thyroglossal cysts rise during tongue protrusion.
Discuss the different types of goitre
- Diffuse goitre: the whole thyroid gland is enlarged due to hyperplasia of the thyroid tissue.
- Uninodular goitre: the presence of a single thyroid nodule which may be active (toxic) autonomously producing thyroid hormones (causing hyperthyroidism) or inactive.
- Multinodular goitre: the presence of multiple thyroid nodules which may be active or inactive. Active multinodular goitres are often referred to as a toxic multinodular goitre.
Describe proximal myopathy
Proximal myopathy is a potential complication of both multinodular goitre and Graves’ disease.
Patients develop wasting of their proximal musculature causing difficulties in tasks such as standing from a sitting position.
To screen for proximal myopathy ask the patient to stand from a sitting position with their arms crossed (to minimise their ability to mask proximal muscle weakness). Make sure to stand close to the patient to prevent them from falling. An inability to stand up would suggest proximal muscle weakness.
Describe pretibial myxoedma
Pretibial myxoedema is a form of diffuse mucinosis in which there is an accumulation of excess glycosaminoglycans (from hyaluronic acid) in the dermis and subcutis of the skin.
It usually presents itself as a waxy, discoloured induration of the skin on the anterior aspect of the lower legs (pre-tibial region).
Pretibibial myxoedema is a rare complication of Graves’ disease
Describe thyroid acropachy
- Similar in appearance to finger clubbing but caused by periosteal phalangeal bone overgrowth
- Secondary to Graves’ disease.
State the local lymph nodes which should be examined during a thyroid exam
- Submental
- Submandibular
- Pre-auricular
- Post-auricular
- Superficial cervical
- Deep cervical
- Posterior cervical
- Supraclavicular
Discuss the clinical relevance of the mobility of a thyroid mass on tongue protrusion
Ask the patient to protrude their tongue:
- Thyroglossal cysts will move upwards noticeably during tongue protrusion.
- Thyroid gland masses and lymph nodes will not move during tongue protrusion.
State some typical features of different causes of an enlarged thyroid gland (Graves’ Disease, Toxic Nodular Goitre, Malignancy)
List the components of the Mini Mental State Exam
- Appearance and behavior
- Speech
- Mood and affect
- Risk (although not technically a component, it is an important factor)
- Thought (form and content)
- Perception
- Cognition
- Insight and judgement
Discuss the appearance and behaviour section of the mini MSE
Use adjectives
- Appearance: Build, posture, dress, grooming, prominent physical abnormalities
- Behaviour: Agitated, aggressive, pacing, relaxed, withdrawn
- Rapport: Established or not
- Level of alertness: Drowsy, alert
Description can vary between clinicians – based on your own experiences (what does agitated look like to you? etc.)
Appearance and behaviour can change how you conduct the examination i.e., open questions may not be useful for someone giving short answers
Rapport can be difficult to establish sometimes i.e., severe depressive episode or paranoid schizophrenia
Eye contact: Poor / good / intense
Psychomotor activity: Retardation / agitation
Movements: Tremor / abnormal movements
Other signs
Mannerisms: Odd purposeful movements
Stereotypes: Non-goal directed movements
Tics: Sudden involuntary movements.
Discuss the speech section of the mini MSE
This is an observed section of the MSE - you don’t ask questions about it.
Consider
- Quantity - Possible descriptors: • Talkative, spontaneous, expansive, paucity, poverty.
- Rate - Possible descriptors: • Fast, slow, normal, pressured.
- Tone and Volume - Possible descriptors: • Loud, soft, monotone, weak, strong.
- Fluency and Rhythm - Possible descriptors: • Slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic.
Consider rhythm, rate, and tone (also quantity)
- Can you get a word in? Is it verbal diarrhoea?
- Fluency is important in old age psychiatry – i.e., word finding difficulty
- Fluency may be disrupted if some one has auditory hallucinations i.e., they pause speech to listen to someone/something else
Discuss the perception section of the mini MSE
Reception and processing of sensory information
Discuss the insight and judgement section of the mini MSE
- Awareness of one’s own symptoms
- Attribution of symptoms to mental disorder
- Appraisal or analysis of consequence of the disorder
- Acceptance of treatment
- In a continuum rather than all or none
May change due to treatment, severity of illness etc.
Discuss features of disorder of possession of thought (thought insertion, thought withdrawal, thought broadcast, thought blocking, obsessions)
Describe different types of perceptual disturbance
Discuss the differences between true hallucinations and pseudo-hallucinations
Discuss the flow chart followed if a collapsed patient is found in a hospital setting
Discuss the ALS (adult life support) flow chart
