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OSCEs > Thyroid Examination > Flashcards

Thyroid Examination Flashcards

1
Q

Broadly, what are the stages of a thyroid examination?

A
  1. Introduction
  2. General Inspection
  3. Hands
  4. Pulse
  5. Face
  6. Eyes
  7. Thyroid Inspection
  8. Thyroid Palpation
  9. Lymph Node Palpation
  10. Trachea Palpation
  11. Percussion of the Sternum
  12. Auscultation of the Thyroid Gland
  13. Further tests
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2
Q

What is involved in the introduction of a thyroid examination?

A
  1. Wash your hands and don PPE
  2. Introduce yourself (name + role)
  3. Confirm their name and date of birth
  4. Briefly explain the examination
  5. Gain consent
  6. Get them to sit in a chair and adequately expose neck and upper sternum
  7. Ask if they have any pain before starting
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3
Q

What are you looking for in the general inspection section of a thyroid examination?

A

CLINICAL SIGNS

  • Weight (gain or loss of it)
  • Behaviour (anxiety, hyperactivity, low mood)
  • Clothing
  • Hoarse voice

OBJECTS + EQUIPMENT

  • Mobility aids
  • Prescriptions
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4
Q

If someone reports low mood in a thyroid examination, what could this be indicative of?

A

Hypothyroidism

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5
Q

If you notice someone is anxious or hyperactive in a thyroid examination, what could this be indicative of?

A

Hyperthyroidism

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6
Q

What pathology of the thyroid may cause the patient to have a hoarse voice? Why?

A

Caused by compression of the larynx due to thyroid gland enlargement (eg. thyroid malignancy)

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7
Q

Why may someone suffering from a thyroid pathology have a walking aid?

A

Patients with hyperthyroidism can develop proximal myopathy

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8
Q

When inspecting the hands in a thyroid examination, what are you looking for?

A
  • Thyroid acropachy
  • Onychlysis
  • Palmar erythema
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9
Q

What is thyroid acropathy? What does it indicate?

A

It is similar in appearance to finger clubbing but caused by periosteal phalangeal bone overgrowth secondary to Graves’ disease.

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10
Q

What is oncycholysis? What does it indicate?

A

It is the painless detachment of the nail from the nail bed associated with hyperthyroidism.

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11
Q

What causes palmar erythema?

Hint: 3 things

A
  • Hyperthyroidism
  • Chronic liver disease
  • Pregnancy
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12
Q

Aside from inspecting the hands, what else do you do in this stage of the thyroid examination? How? What does it indicate?

A

Check for a peripheral tremor by placing a piece of paper over the backs of their hands as they hold them out straight.

Peripheral tremor is a feature of hyperthyroidism reflecting sympathetic nervous system overactivity.

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13
Q

After inspecting and checking the hands in a thyroid examination, what is next?

A

Check the radial pulse for rate and rhythm.

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14
Q

What is the normal pulse?

A

60-100bpm

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15
Q

What is bradycardia? What can cause it?

A

A heart rate of less than 60bpm

Seen in

  • Healthy athletic individuals
  • Hypothyroidism
  • AV block
  • Etc.
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16
Q

What is tachycardia? What can cause it?

A

A heart rate greater than 100bpm

Seen in:

  • Hyperthyroidism
  • Anxiety
  • Supra-ventricular tachycardia
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17
Q

What irregularity to the rhythm of the pulse is associated with hyperthyroidism?

A

An irregular rhythm is most commonly caused by atrial fibrillation which can be associated with hyperthyroidism.

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18
Q

What are you looking for in the face as part of a thyroid examination?

A
  • Dry skin
  • Excessive sweating
  • Outer 1/3 eyebrow loss?
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19
Q

If a patient has dry skin, what can this indicate?

A

Hypothyroidism

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20
Q

If a patient is excessively sweating, what can this indicate?

A

Hyperthyroidism

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21
Q

What is the link with thyroid pathology and eyebrows?

A

A rare sign of hypothyroidism is the absence of the outer third of the eyebrows

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22
Q

What do you do for the ‘eye’ section of the thyroid examination?

A

INSPECTION

  • Lid retraction
  • Exophthalmos
  • Eye inflammation

TESTS

  • Eye Movements
  • Lid Lag
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23
Q

What is lid retraction? What does it indicate?

A

This is when your upper eyelid is retracted, meaning you can see sclera above the eyes.

It is the most common ocular sign of graves disease, however can be present in other thyrotoxic states (ex. toxic multinodular goitre)

24
Q

What is exophthalmos? What does it indicate?

A

Anterior bulging of the eye out of the orbit.

Bilateral exophthalmos develops in graves disease due to oedema and lymphatic infiltration of orbital fat, connective tissue and extra-ocular muscles.

25
Q

How do you check for exophthalmos?

A

Look at the eye from the front, side and from above

26
Q

What thyroid physiology would you suspect if there is unilateral exophthalmos?

A

None. this indicates an orbital tumour

27
Q

Why may there be eye inflammation in someone with thyroid pathology?

A

Due to lid retraction and exophthalmos, the eye is more prone to dryness and the development of

  • conjunctival oedema (chemosis)
  • conjunctivitis
  • in severe cases, corneal ulceration
28
Q

What are you looking for in a thyroid examination when testing eye movements?

A
  • Evidence of opthalmoplegia (restricted eye movements)
  • Evidence of pain during eye movement

Both of these are caused by graves disease due to the swelling behind the eye

29
Q

What is the lid lag test?

A

Lid lag refers to a delay in the descent of the upper eyelid in relation to the eyeball when looking downward.

30
Q

How do you test for lid lag?

A
  1. Hold your finger superiorly and ask the patient to follow it with their eyes, whilst keeping their head still.
  2. Move your finger downwards whilst observing the patients upper eyelid.

If lid lag is present, you will be able to see their superior sclera as the upper eyelid lags behind the movement of the eye.

31
Q

What is a positive lid lag indicative of?

A

It is most commonly associated with graves disease, but it can be present in other thyrotoxic states

32
Q

After inspecting and testing the eyes in a thyroid examination, what do you do next?

A

Inspect the thyroid

33
Q

How do you go about inspecting the thyroid?

A

Inspect the midline of the neck from the front and the sides, noting any masses (ex. goite) or scars (ex. previous thyroidectomy)

34
Q

Should you normally see the thyroid gland?

A

No

35
Q

If you see a mass of the thyroid in an examination, what should you do next?

A

Need to perform further tests to narrow down differentials.

SWALLING WATER

  • If mass moves upwards, it indicates either thyroid gland masses (ex. goitre) or thyroglossal cysts
  • If it stays where it is, it could be an enlarged lymph node, or an invasive thyroid malignancy

TONGUE PROTRUSION

  • Thyroglossal cysts will move upwards noticeably during tongue protrusion.
  • Thyroid gland masses and lymph nodes will not move during tongue protrusion.
36
Q

After seeing a mass around the thyroid, how do you distinguish between a thyroglossal cyst and a thyroid gland mass such as a goitre?

A

Swallowing water test is not that helpful as in either case, the mass will move upwards when you swallow.

You distinguish via tongue protrusion test. If the mass move upwards, it indicates a cyst. If it stays still, it indicates a thyroid gland mass

37
Q

What is involved in palpating the thyroid?

A
  1. Ask them to point their chin downwards slightly to relax neck muscles.
  2. From behind, place the 3 middle fingers of each hand along the midline of the neck
  3. Locate the upper edge of the thyroid cartillage and move down until the cricoid cartillage. Then go down 2 tracheal rings, and this is where the isthmus is
  4. Palpate the isthmus, and then each lobe in turn
  5. Ask the patient to stick their tongue out, and then swallow water whilst you feel for the symmetrical elevation of the thyroid lobes
38
Q

Whilst palpating the thyroid, what would a unilateral elevation of the thyroid in response to swallowing indicate?

A

Unilateral thyroid mass

39
Q

If you feel a mass on the thyroid rise during tongue protrusion, what does it indicate?

A

Thyroglossal cyst

40
Q

What characteristics of the thyroid gland should you comment on after palpation?

A
  • Size (ie. normal, enlarged etc.)
  • Symmetry
  • Consistency (does it all feel the same)
  • Masses (are there any distinct palpable masses within the thyroid tissue
  • Palpable thrill
41
Q

What would widespread irregular consistency of the thyroid indicate?

A

Multi nodular goitre

42
Q

When would you feel a palpable thrill of the thyroid?

A

If there is increased vascularity of the thyroid gland, which is due to hyperthyroidism, suggestive of graves disease

43
Q

What should you comment on if you feel a thyroid mass?

A
  • Position
  • Shape
  • Consistency
  • Mobility (ie. is it tethered to underlying tissue)
44
Q

After palpating the thyroid gland, what is next in the thyroid examination?

A

Lymph node palpation

45
Q

Which lymph nodes do you examine as part of the thyroid examination?

A
  • Submental
  • Submandibular
  • Pre-auricular
  • Post-auricular
  • Superficial cervical
  • Deep cervical
  • Posterior cervical
  • Supraclavicular
46
Q

What technique should you use when palpating the lymph nodes?

A

You have to use the pads of your 2nd, 3rd and 4th fingers to press and roll the lymph nodes over the surrounding tissue, as opposed to just using your fingertips.

47
Q

After palpating the lymph nodes, what is next in a thyroid examination?

A

Inspect the trachea for evidence of tracheal deviation, which may be caused by a large goitre

48
Q

After inspecting the trachae, what is next in the thyroid examination? What are you looking for?

A

Percuss the sternum moving downwards from the sternal notch.

Retrosternal dullness may indicaate a large thyroid mass extending posteroinferiorly to the manubrium.

49
Q

After percussing the sternum, what is next in the thyroid examination?

A

Auscultation of the each lobe of the thyroid gland with the bell to see if there is a bruit

50
Q

What does a thyroid bruit indicate?

A

A bruit indicates increased vascularity, which typically occurs in Graves’ disease.

51
Q

What 3 further tests are part of the thyroid examination?

A
  1. Reflexes
  2. Pretibial myxoedema
  3. Promixal myopathy
52
Q

How do you test reflexes in the thyroid examination? What are you looking for in order to diagnose?

A

Reflexes are assessed to screen for hyporeflexia, which is associated with hypothyroidism. And hyperreflexia for hyperthyroidism

The most commonly tested reflexes are the biceps reflex or the knee jerk reflex, however you only need to assess one.

53
Q

What is pretibial myxoedema? What is the relevance of it in a thyroid examination?

A

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.

54
Q

What is proximal myopathy? What is the relevance of it?

A

Proximal myopathy is a potential complication of hyperthyroidism

Patients develop wasting of their proximal musculature causing difficulties in tasks such as standing from a sitting position.

55
Q

How do you test for proximal myopathy?

A

To screen for proximal myopathy ask the patient to stand from a sitting position with their arms crossed

An inability to stand up would suggest proximal muscle weakness.

Make sure you stand close to them to prevent them from falling.

56
Q

How do you finish an examination in an OSCE?

A
  • Explain to the patient and examiner that it is now finished
  • Thank the patient for their time
  • Dispose of PPE appropriately and wash your hands
  • Summarise your findings
57
Q

What further assessments and investigations would you order to complete a thyroid examination?

A

BEDSIDE TESTS

  • ECG (if there was an irregular pulse to rule out AF)

LABORATORY TESTS

  • Thyroid function tests (TSH, T3 and T4)

FURTHER IMAGING

  • Ultrasound of the neck to assess any further thyroid lumps

OSCEs (3 decks)

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