Thyroid Gland Examination for Medical Student OSCE
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“I have been asked to examine your thyroid, a gland in your neck, and all the parts of the body affected by the gland”
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Introduce, identify, explain, consent. WASH HANDS!
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General inspection
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Over / underweight
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Tremor (hyperthyroid)
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Sweating (hyperthyroid)
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Clothing: appropriate for temperature?
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Hair dry / hair loss
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Pretibial myxoedema
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Neck: scars, goitre, distended neck veins
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Hands
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Clubbing (thyroid acropachy) (hyperthyroid – Grave’s disease)
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Onycholysis - both
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Palmer erythema (hyperthyroid)
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Postural tremor – rest paper on hands
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Sweatiness
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Myxoedema
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Pulse
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Fast in hyperthyroidism. AF possible
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Slow in hypothyroidism
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Blood pressure
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Eyes / face
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Exophthalmos (hyperthyroid – Grave’s disease) or proptosis (forward displacement of eyes)
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Lid lag (hyperthyroid)
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Lid retraction: sclera visible above cornea (hyperthyroid)
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Double vision: ophthalmoplegia: on testing eye movement – Grave’s disease
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Face has ‘toad-like’ appearance in hypothyroidism due to non-pitting oedema e.g. on eyelids
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Back of throat for undescended thyroid
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Eyebrows (lat 1/3 – hypo), hair, skin
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Neck + thyroid gland
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Inspection
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Look closely – lumps, pigmentation, vasculature
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Stick tongue out
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From front: ask pt to swallow glass of water. Watch for thyroid swelling moving upwards. Not rising suggests malignant change, though also very large goitres will not rise. May alternatively be thyroglossal cyst: ask pt to stick tongue out, cyst moves upwards in midline.
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Palpation – from behind
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Lymph nodes
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Ask pt to sit with neck muscles relaxed. Place hands on thyroid lightly from behind, with middle fingers just touching. (Warn this may be unpleasant). Palpate 1 side at time. Pt swallows another sip of water
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Tenderness – suggests viral thyroiditis
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Shape and surface: usually smooth and diffuse in Graves; irregular in uninodular / multinodular goitre
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Size? – Measure discrete nodules with callipers.
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Very hard nodule – suggests malignant change. Large, firm lymph nodes near goitre also suggest thyroid cancer
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Thrill due to abnormally high blood flow in hyperthyroidism.
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From front - trachea
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Percussion – for retrosternal thyroid / goitre
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Auscultation – thyroid bruit indicates high blood flow, in hyperthyroidism. Bruit louder along line of artery if it is in reality an aortic or carotid bruit.
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Legs
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Ask patient to stand up. Turn round – ankle reflex (slow relaxing: hypothyroidism). And sit again, with arms held crossed across chest – peripheral myopathy
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Pretibial myxoedema. Non-pitting oedema, tibial and dorsum of foot. Rare sign in Grave’s disease hyperthyroidism.
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Further tests
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Hyperthyroidism:
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Eye test – visual fields, acuity, eye movements: opthalmopathy present?
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T4 and T3↑, TSH↓, thyroid antibodies present + USS thyroid
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Thyroid scan if subacute thyroiditis suspected
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Hypothyroidism:
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ECG – bradycardia, low-voltage complexes
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Bloods: TFTs: T4↓, TSH↑ in 1?, ↓ in 2?/3?
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Thyroid differential: thyrotoxicosis, hypothyroidism and thyroid carcinoma. Causes of thyroid swellings: mnemonic GOITRE
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Graves’ disease; Goitogrens (broccoli, lithium)
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Onset of puberty
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Iodine deficiency
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Tumour; Thyroiditis (Hashimoto’s); Thyrotoxicosis
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Reproduction: pregnancy
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Enzyme deficiencies – dyshormonogenesis
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Midline swellings can be caused by thyroid swellings, thyroglossal cysts, lymph nodes, and sublingual dermoid cysts
Thyroid carcinoma: 3 types: papillary (young), follicular (middle aged), anaplastic (elderly) (reverse alphabetical order). Thyroid swelling often is hard and irregular, indistinct edge. Structures can be infiltrated, e.g. oesophagus, trachea, RLN and local muscles ? dysphagia, dyspnoea, stridor, hoarseness of voice
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Word Count: 1082
Date: Fri, 22 Jan 2010 Time: 4:04 PM
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