Phys Di - Thyroid Flashcards
What are the endocrine ROS?
- growth & development issues
- abnormal hair growth and/or patterns
- polyuria, polydipsia, polyphagia
- h/o diabetes, h/o thyroid issues
- galactorrhea
- diaphoresis
- temperature intolerance
What are the neck ROS?
- Swelling
- Lumps
- Goiter
- Pain
- Limitation of Movement
What types of past medical history would you want to ask about?
- h/o thyroid issues
- menstruation
- sleep disturbances
- changes in appetite
- weight loss/gain
- depression
What types of surgical history would you want to ask about?
- surgeries in the neck or chest
- past thyroid surgeries
What types of family history would you want to ask about?
Family h/o diabetes or thyroid disease
What types of social history would you want to ask about?
- drugs
- alcohol
- ask the patient how you cope with stress/what is your stress level?
What do you inspect on the neck?
- Thyroid for masses/size (have patient extend neck)
- Tracheal deviation
- Carotid pulsations
- Jugular venous pulsations/distention
Explain how to palpate the thyroid
palpate both lobes from behind for masses/fullness; ask patient to swallow; have patient turn head to each side
State the lymph nodes on the physical exam
- Anterior Cervical – side of the neck
- Posterior Cervical – back of the neck
- Occipital – base of the skull
- Preauricular – in front of the ear
- Postauricular – behind the ear on the mastoid bone
- Tonsillar – at angle of the jaw
- Submandibular – under the jaw bone
- Submental – underneath the chin
- Supraclavicular – just above the clavicle
Give 3 facts about the thyroid gland
- Largest endocrine gland
- Located on each side of the trachea, joined by the isthmus
- Produces thyroid hormone (T3, T4)
Outline the inspection of the thyroid
- From anterior and from lateral, ask patient to extend neck
- Visualize landmarks (thyroid cartilage, cricoid cartilage, trachea)
- Symmetry: does the neck look equal on both sides and there is straight line down to sternal notch?
- Masses
- Fullness
- Tracheal position/deviation: note that trachea is midline
- Ask the patient to swallow as you inspect …
Why would the examiner inspect as the patient swallows?
- helps examiner identify the thyroid tissue more accurately
- thyroid and trachea move together
- to evaluate a neck mass
How does normal swallowing affect the thyroid?
thyroid/trachea make an UPWARD movement of 2-3 cm, hesitates (< 1 sec), and then returns to original position
How can you tell if a mass is in the thyroid?
A mass is NOT in the thyroid if it doesn’t move during a swallow or it moves less than the thyroid cartilage.
e.g. a subcutaneous nodule or mass will NOT move with the swallow
What do you palpate for?
-Enlargement a.k.a. thyromegaly, goiter
-Tenderness (e.g. thyroiditis)
-Consistency (soft vs. firm)
“soft” = same consistency of the surrounding tissue = normal
-Firm in Hashimoto’s, malignancy
-Texture (smooth vs. nodular)
Outline the posterior approach technique
- Be gentle! “Drift” over the gland
- Use pads of 2-3 fingers (index, long, +/- ring)
- Locate thyroid cartilage (Adam’s apple) first, then “map out” other anatomy
- Ask patient to swallow with pads of fingers still on neck
- Lateral lobes are lateral to trachea and will rise during swallow
- Palpate both lateral lobes simultaneously
- Have patient turn head away (R) to palpate left lobe and vice versa. Especially if you’re feeling something abnormal* questionable based on guest lecturer*
- May need a second swallow (+/- water?)
Palpation of thyroid
- what does normal feel like?
- May be non-palpable
- Lobes should be small
- Texture should be smooth
- Non-tender
- Lobes should rise symmetrically with swallowing
- Right lobe might be slightly larger than left
Palpation of thyroid
- what is abnormal?
- Enlarged/full = goiter
- Coarse or gritty (inflammation)
- Nodules (tiny masses)
- Asymmetry of lobes
- Tenderness (inflammation)
Define goiter
an enlarged thyroid
*Note if unilateral, diffuse, nodular
What is “rule of thumb” for the thyroid?
“Rule of thumb” : a lobe is enlarged if larger than the distal phalanx of the patient’s thumb
When should you auscultate the thyroid?
-technique
**verbalize only for SPBL
- Only helpful if goiter is present
- Bell slightly better than diaphragm
- If blood flow is increased (hyperthyroidism), a vascular bruit (soft, rushing sound) can be heard
Characterize thyroid nodules
- Occur in 5% of women and 1% of men
- Most are NOT palpable
- Mean diameter of a palpable nodule is 3 cm
- If you palpate a nodule, note size and fixed vs. mobile
What does it mean if a nodule moves with swallow?
If yes, it is attached to the thyroid
What is the best diagnostic test to evaluate a thyroid nodule?
fine-needle aspiration (FNA)
Hypothyroidism
-skin and soft tissue findings
- NON-pitting edema a.k.a. myxedema
- Periorbital edema
- Coarse, thin hair and eyebrows
- Yellow skin due to ↓ conversion of carotenoids to retinol
- Cool skin due to ↓ dermal blood flow
- Dry skin due to ↓ sebum production
What is myxedema?
Dermal accumulation of mucopolysaccharides that freely bind water: “jelly-like swelling and overgrowth of mucus-yielding cement” which led Ord to coin the term myxedema in 1877
Hypothyroidism
-neurological findings
- Delayed reflexes
- Hypothyroid Speech
- -1/3 of hypothyroid patients
- -Slow rate and rhythm
- -Low-pitched, and hyponasal, sounds like they have a cold
Is obesity more or less common in hypothyroidism?
Obesity is NO MORE COMMON in hypothyroid patients than in euthyroid patient!
What is the MCC of hyperthyroidism?
Grave’s disease
Physical findings in hyperthyroidism
- general
- eye
- 70-93% have a goiter (diffuse and symmetrical)
- thyroid bruit (up to 73%)
Eye findings:
- -Lid lag: white sclera seen when looking down
- -Lid retraction
- -Bilateral Exophthalmos
Physical findings in hyperthyroidism
-skin
- -Warm, moist, and smooth due to ↑ sympathetic tone to sweat glands and ↑ dermal flow
- -Pretibial myxedema –> bilateral, asymmetrical raised firm plaques/nodules, pink to purple-brown, over anterior shins
Physical findings in hyperthyroidism
- neuromuscular
- Weakness and diminished exercise tolerance
- Fine hand tremor due increased sympathetic tone
- Brisk reflexes
Physical findings in hyperthyroidism
- cardiovascular
- Tachycardia > 90 beats/min
- Symptom of palpitations
Physical findings of Cushing’s syndrome (hypercortisolism)
- Moon facies
- Buffalo hump
- Wide purple striae
- Pendulous abdomen
- Central fat distribution
- Periorbital edema
- Thin skin
- Supraclavicular fat pads
- Acne
Physical findings of Addison’s Disease (1⁰ Adrenal Insufficiency)
- Hyperpigmentation
- Bronze skin
- Vitiligo
- Loss of body hair
- Oral mucous membrane hyperpigmentation
Physical findings of Hypoparathyroidism (↓ calcium, ↑ phosphate)
- Tetany
- Trousseau’s Sign: carpal spasm induced by inflation of BP cuff
- Chvostek’s Sign: facial twitch caused by percussion of facial nerve
- Hair Loss
- Cataracts
- Papilledema
Other physical findings
- Diabetic Cheiropathy (AKA Stiff Hand Syndrome)
- Acanthosis Nigricans (often seen in insulin resistance)
Causes of gynecomastia
- CKD
- Cirrhosis
- Drugs
- Hyperthyroidism
- Hypogonadism
- Testicular tumors
- Ectopic Production of hCG
- Feminizing Adrenocortical Tumor
