Foreword by Dr.Lingham/Dr.Arul We have attempted to create notes for clinical skills for year 2.

This notes will help facilitate the revision classess conducted every Monday by Dr.Lingham and Dr.Arul. We must admit that these notes are not exhaustive . The notes have been made based on 2 reference books(Macleod and Talley). Students must never use it as a replacement to the above textbooks,rather use it concurrently with the textbooks. Some procedures and tests were deliberately not explained so that students will refer to their textbooks. The purpose of the notes is to help create a flow in the examination of the various systems. Students must know that these notes are not a replacement to your standard notes that have been given.If there are any discrepancies please refer to us. Common symptoms in thyroid disease Occasionally students are required to determine if a patient is clinically hypothyroid,euthyroid or hyperthyroid. This assessment would require relevant history taking and physical examination to determine thyroid status. Symptoms to look for in thyrotoxicosis would be 1)Loss of weight eventhough there is an increase in apetite 2)Palpitations especially at rest 3)Heat intolerance-patients frequently complain that they feel warm even on cold days 4)Anxiety and agitation-family members/friends will notice that the patient is always anxious and is always busy and frequently gets angry. 5)Tremors 6)Irregular periods with oligomennorhea 7)Difficulty in climbing stairs or standing up from a seated position-indicating proximal myopathy. 8)Hair loss 9)Neck swelling-this can be present even in hypothyroidism 10)Eye symptoms-bulging eyes,swollen eyelids,diplopia would indicate Graves disease as a cause. Symptoms to look for in hypothyroidism 1)Lethargy 2)weight gain 3)loss of hair 4)mennorhagia 5)change in voice 6)cold intolerance-inability to withstand cold surroundings. 7)slow mentation 8)neck swelling

It is always more difficult to diagnose hypothyroidism because the initial symptoms can always mimic depression,Due to more extensive screening we are now identifying patients with hypothyroidism earlier.A high index of suspicion is essential. It is viatl to know that patients with hyperthyroidism can present with high output cardiac failure and those with hypothyroidism with ischaemic heart disease.

Clinical signs for hyperthyroidism Prepared by Dr.Arul/Dr.P.V.Lingham

General: Look for evidence of weight loss. Patient may appear restless or agitated or anxious. A staring appearance or obvious exopthalmous. Hand tremors. Visible enlargement at the neck. Hyperthermia Hands: Palms warm and moist. Palmar erythema. Thyroid acropachy ie clubbing .(Graves Disease) Confirm fine tremor in hands . Pulse tachycardia, atrial fibrillation, collapsing pulse( wide pulse pressure- normal is 30mmHg-60mmHg) Biceps/brachioradialis reflex _ hyperreflexia. BP Systolic hypertension.Diastolic <90 Systolic>150(wide pulse pressure) Abduct upper arms against resistance.Stand up from squatting position.(this is to check for proximal myopathy) Examinationof the face : Skin sweaty and oily. Examination of the eyes : Periorbital oedema..( lymphocytic infiltration and deposition of glycosaminoglycan in the extraocular muscles) Conjunctival injection and chemosis Exophthalmous(Graves Disease). Lid retraction-sympathomimetic overactivity Lid lag sympathomimetic overactivity. Opthalmoplegia paresis of extraocular muscles.Check for diplopia.Classically the inferior rectus is affected first.(Graves Disease) Examination of the neck: On inspection there will be a swelling at the neck .There sould be no change in colour or

Texture of the overlying skin.The thyroid gland moves on swallowing .( Reason:Thyroid gland is enclosed in pretracheal fascia which is attached to the cricoid cartilage ) Protrude tongue. If moves up , thyroglossal cyst.(reason : arises from foramen caecum ) Stand behind patient, Look at the patients face while palpating the swelling. Assess characteristics of the swelling(size,shape,consistency,surface. Is there any palpable thrill. Auscultate for bruit. Palpate the cervical lymph nodes. Presence of lymph nodes indicates possible carcinoma of thyroid. Percuss over manubrium for retrosternal extension.Elicit Pembertons sign to detect retrosternal extension. Examination of the cardiovascular system: Sinus tachycardia. Atrial fibrillation. Evidence of heart failure displaced apex beat,raised JVP, crepitations in lungs. Systolic flow murmur of hyperdynamic circulation. Examination of the Abdomen : Splenomegaly.(in Graves Disease) Examination of the Lower Limbs : Pretibial myxoedema.(Graves Disease)

The above findings are consistent with thyrotoxicosis but one must not be mistaken that signs of thyrotoxicosis are similar to signs of Graves Disease.A patient can have Graves Disease and yet be clinically euthyroid.

Clinical signs of A patient with hypothyroidism General appearance: Coarse features with dry skin. Hoarse or Husky voice. Obese/Weight gain. Mental slowness Myxoedemal madness psychosis/dementia Generalised hair thinning with loss of outer third of eyebrows Hypothermia Deafness(Pendreds Syndrome) Hands : Palms are cold and dry. There can be yellowish discolouration of palms secondary to hypercarotenaemia. Palmar creases can be pale due to anaemia Carpal tunnel syndrome.(Ask the patient if there is any numbness in the hands) Pulse bradycardia. Biceps jerk delayed relaxation phase. BP diastolic hypertension ( > 90mmHg )

Face -alopecia -vitiligo might indicate an autoimmune thyroid disorder. -periorbital edema -xanthalesma -loss of outer third of eyebrows. -swollen tongue Neck: Visible enlargement of the thyroid gland (goitre) Palpate and describe gland.An enlarged gland can be due to Hashimotos thyroiditis, Iodine deficiency,enzyme deficiencies in thyroid hormone synthesis. Absence of an enlarged gland can be secondary to thyroidectomy(surgical scar will be present),agenesis,atrophic hypothyroidism Cardiovascular system:

Pericardial effusion = absence of apex beat, soft heart sounds. Ischaemic heart disease Hypercholestrolaemia Lower limbs: Ankle jerk delayed relaxation. Non-pitting oedema.

We will attempt to show a systematic examination of someone with thyroid disease and to assess his/her thyroid status. 1)Introduce yourself 2)Explain procedure and obtain consent.It is important to expose the neck adequately. 3)General Inspection -Is the patient wasted(hyper)/obese(hypo) -is the patient agitated(hyper) or appears slow/inactive(hypo) -has the patient got a staring gaze -is the the patient hyper(hyper) or hypothermic(hypo) -is the voice hoarse(hyper) -skin is coarse and dry(hypo).May appear yellow due to hyper carotenaemia. 4)Examination of the hands -is the hand cold and dry(hypo) or warm and moist(hyper) -is the skin coarse(hypo) -are there fine tremors -clubbing(Graves) -palmar erythema -carpal tunnel syndrome in hypothyroidism -yellow discolouration (palms)in hypoythyroidism -pallor of palmar creases due to anaemia(hypo) 5)Pulse -bradycardic in hypothyroidism -tachycardic/atrial fibrillation in hyperthyroidism -collapsing pulse in hyperthyroidism -hyperreflexia in biceps/bachioradialis reflex in thyrotoxicosis -in hypothyroidism reflexes are best checked by doing the ankle jerk The relaxation phase is slow

6)Reflexes

7)Blood pressure increased in thyrotoxicosis with wide pulse pressure 8)Check for proximal myopathy by asking the patient to abduct his upper limbs against resistance. 9)Examination of the head -Thinning of hair -Exophthalmous/proptosis -Lid lag -Lid retraction -Chemosis -Conjunctivitis(due to exposure) -loss of eyebrows(hypo) -large tongue(hypo) -periorbital edema(hypo) -xanthalesma(hypo) 10)Examination of the neck -Goitre-identify if there is a diffuse swelling or localized swelling(nodule) -Describe swelling(surface,consistency,size,tenderness,edge,mobility) -Examine for palpable thrill and auscultate for bruit -Examine for retrosternal extension by percussing on the manubrium and eliciting Pembertons sign -Examine for palpable lymph nodes 11)Examine the praecordium if indicated for -displaced apex beat due to cardiomegaly(both hyper/hypothyroidism can cause heart failure. -Systolic murmur might be present (flow murmur in thyrotoxicosis) -pericardial effusion in hypothyroidism 12)Examine the abdomen if Graves is suspected for splenomegaly 13)Examine the lower limbs for pretibial myxedema(Graves) and slow relaxation phase of the ankle reflex.(hypo) During the examination several findings can help us arrive at a diagnosis A solitary nodule with signs of thyrotoxicosis would suggest solitary toxic nodule

A diffuse goiter with signs of thyrotoxicosis would suggest diffuse toxic goiter, early Hashimotos thyroiditis or Graves disease(there will be other signs of graves disease) A hard thyroid gland might suggest carcinoma of the thyroid or Riedles thyroiditis. Investigations in thyroid disease 1)Free T4,T3 AND TSH levels.All three readings have to be assessed together. In thyrotoxicosis the FT4 and FT3 will be raised and the TSH will be low In hypothyroidism the FT4 and FT3 will be low but the TSH will be high(primary hypothyroidism).I f the TSH is also low the problem is in the pituitary. 2)Ultrasound of the thyroid gland-will indicate diffuse goiter,multinodular goiter,solitary nodule. 3)E.C.G-tachycardia/atrial fibrillation in thyrotoxicosis,bradycardia in hypothyroidism 4)radioisotope thyroid scan 5)percutaneous fine needle aspiration biopsy for thyroid nodule (cystic/solid) Prepared by Dr.Arul/Dr.Lingham