Physical Examination: Thyroid Gland

Assessment of the Thyroid Gland through Physical Examination

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Physical Examination: Thyroid Gland (DokJosePH on YouTube)

Lumps in the neck are relatively common and although the majority are benign in nature they can sometimes be the first signs of more sinister pathology such as malignancy. It is therefore essential that you are able to competently perform neck lump examination. This guide demonstrates how to examine a patient with a neck lump in your OSCE, visit our thyroid status examination guide for instructions on how to perform a detailed thyroid gland assessment. Check out the the neck lump examination mark scheme here.

 

Introduction

  • Maghugas ng kamay
  • Ipakilala ang sarili

“Magandang umaga. Ako po si ____________. Ako po ay isang doktor/mag-aaral ng medisina.”

  • Siguraduhin ang detalye ng pasyente (pangalan at kaarawan)

“Ano po ang pangalan nila? Kailan po sila ipinanganak?”

  • Ipaliwanag ang gagawing eksaminasyon

 

“Ngayon po, tayo ay magsasagawa ng mga ilang eksaminasyon sa kanilang leeg. Titignan po natin ito. Mamaya naman po ay hahawakan ko din para mas matignan ng mabuti.”

  • Kumuha ng pahintulot

“Ayos lang po ba iyon?”

  • Iposisyon nang tama at wastong nakikita ang leeg

 

General inspection

  • Voice – weak / hoarse?
  • Identify any scars on the neck – previous surgery (e.g. thyroidectomy)
  • Observe for any obvious masses in the neck
    • If a mid-line lump is present:
  1. Ask the patient to swallow some water – thyroid masses will rise / as will thyroglossal cysts

“Maaari po ba silang lumunok?” or “Puwede niyo po bang inumin itong tubig?”

  1. Ask patient to protrude tongue – thyroglossal cyst will rise / thyroid masses will not

“Pakilabas po ang kanilang dila”

  1. Look for systemic signs that may relate to neck pathology:

  • Cachexia – malignancy
  • Exophthalmos / proptosis – Graves’ disease
  • If there is a mid-line lump / scar or systemic signs suggestive of thyroid disease, ask the examiner if a full thyroid status exam should be performed.

 

Palpation

“Ngayon naman po ay kakapain naman natin ang inyong leeg”

 

Lymph nodes

  • Lymph nodes can become enlarged for a number of reasons – infection / malignancy
  • Lymph nodes are usually smooth, rubbery, with some mobility.
  • An enlarged, hard, irregular lymph node would be suggestive of malignancy.

Palpate the lymph nodes:

  • Supraclavicular – left sided enlarged lymph node – Virchow’s node
  • Anterior cervical chain
  • Posterior cervical chain
  • Sub-mental
  • Sub-mandibular
  • Occipital
  • Pre-auricular
  • Post-auricular
  • Thyroid gland

 

Palpation of the thyroid gland may not be expected in an OSCE with a neck lump that is not related to the thyroid. However to perform a thorough examination of the neck, this should ideally be included as part of the assessment.

 

Assessing a neck lump

  • Size – width / height / depth
  • Location – can help narrow the differential – anterior triangle / posterior triangle / mid-line
  • Shape – well defined?
  • Consistency – smooth / rubbery / hard / nodular / irregular
  • Fluctuance – if fluctuant, this suggests it is a fluid filled lesion – cyst
  • Trans-illumination – suggests mass is fluid filled – e.g. cystic hygroma
  • Pulsatility – suggests vascular origin – e.g. carotid body tumour / aneurysm
  • Temperature – increased warmth may suggest inflammatory / infective cause
  • Overlying skin changes – erythema / ulceration / punctum
  • Relation to underlying / overlying tissue – tethering / mobility (ask to turn head)
  • Auscultation – to assess for bruits – e.g. carotid aneurysm

“Ngayon naman, pakikinggan ko lang po ang kanilang leeg.”

 

To complete the examination

  • Pasalamatan ang pasyente

“Maraming salamat po. May mga katanungan po ba sila?”

  • Maghugas ng kamay
  • Ibuod ang mga natuklasan
  • Magmunkahi ng mga kailangang karagdagang mga pagsusuri
    • Thyroid status examination
    • Examination of the lymphoreticular system
    • Ultrasound scan of lesion
    • Fine needle aspiration – to allow histological diagnosis
    • Routine bloods – FBC/U+E/CRP – may be useful if considering infection / malignancy
    • Early referral to ENT – if there is suspicion of malignancy / presence of red flags
    • Differential diagnosis of a neck lump

 

Red flags

The following features are red flags that should raise your suspicion of malignancy in the context of a neck lump.

  • Hard, fixed mass
  • > 35yrs old
  • Presence of mucosal lesion in the head or neck
  • A history of persistent hoarseness or dysphagia
  • Trismus
  • Ear pain (referred from tongue base)

 

ANG MGA NILALAMAN AY SINURI AT PINAGTIBAY NI:

Ms. Joanne Manalo – 2nd year medical student, ASMPH

 

Reference: Content based on https://geekymedics.com/neck-lump-examination-osce-guide/

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Physical Examination: Cranial Nerve VIII

Testing for the Vestibulo-Cochlear Nerve (CN VIII)

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Physical Examination: Cranial Nerve VIII (DokJosePH on YouTube)

The cranial nerve examination is often considered one of the most difficult OSCE stations, but with plenty of practice you’ll be fine. The important thing to remember is that in an OSCE you’ll not be required to complete an entire cranial nerve exam in one station. This guide provides a step by step approach to cranial nerve examination, with an included video demonstration.

Introduction

  • Maghugas ng kamay
  • Ipakilala ang sarili

“Magandang umaga. Ako po si ____________. Ako po ay isang doktor/mag-aaral ng medisina.”

  • Siguraduhin ang detalye ng pasyente (pangalan at kaarawan)

“Ano po ang pangalan nila? Kailan po sila ipinanganak?”

  • Ipaliwanag ang gagawing eksaminasyon

“Ngayon po, tayo ay magsasagawa ng mga ilang eksaminasyon sa kanilang leeg. Titignan po natin ito. Mamaya naman po ay hahawakan ko din para mas matignan ng mabuti.”

  • Kumuha ng pahintulot

“Ayos lang po ba iyon?”

  • Iposisyon nang tama at wastong ang ulo ng pasyente

 

Gather equipment

  • 512 Hz Tuning Fork

 

Gross hearing testing

Ask the patient if they have noticed a change in their hearing recently.

“Mayroon po ba kayong napansin na mga pagbabago sa inyong pandining?”

Assess each ear individually, standing behind the patient.

1. Explain to the patient that you’re going to say a word or number and you’d like them to repeat it back to you.

“Pakiulit nga po ang aking sasabihin/ibubulong.”

2. With your mouth approximately 15cm from the ear, whisper a number or word.

3. Mask the ear not being tested by rubbing the tragus or rubbing your fingers near the ear.

“May naririnig po ba kayo? Ano po ang inyong naririnig?”

4. Ask the patient to repeat the number or word back to you.

“Pakiulit nga po ang aking sasabihin/ibubulong.”

5. If the patient repeats the correct word or number, repeat the test at an arms length from the ear (normal hearing allows whispers to be perceived at 60cm).

6. Assess the other ear in the same way.

 

Before performing the Weber’s and Rinne’s tests, allow the patient to hear how the tuning for should sound. Do not forget to describe the procedure.

Weber’s Test

1. Tap a 512 Hz tuning fork and place in the midline of the forehead

2. Ask the patient where they can hear the sound:

“May naririnig po ba kayo?”

“Mas malakas po ba sa alinmang tenga?

“Pantay po ba?”

  • Normal – sound is heard equally in both ears
  • Neural deafness – sound is heard louder on the side of the intact ear
  • Conductive deafness – sound is heard louder on the side of the affected ear

Rinne’s Test

1. Tap a 512 Hz tuning fork and place its base on the mastoid process

2. Ask the patient if they are able to hear it (bone conduction)

“May naririnig po ba kayo?”

3. If they are able to hear it, ask them to let you know when they can no longer hear it

“Pakisabi lang po kapag tumigil na po ang tunog.”

4. Once the patient is unable to hear the sound via the mastoid process move the tuning fork to approximately 1 inch from the external auditory meatus

5. Ask the patient if they are able to hear the tuning fork (this is air conduction)

“Ngayon po, may naririnig po ba?”

6. If the patient is able to hear the tuning fork via air conduction (after they were no longer able to hear via bone conduction) it suggests their air conduction is better than bone conduction (Rinne’s positive).

Summary of Rinne’s test results:

  • Normal = Air conduction > Bone conduction (Confusingly termed “Rinne’s positive”, despite it being the normal result. It is probably best to avoid this term and just describe the result)
  • Neural deafness = Air conduction > Bone conduction (both air and bone conduction reduced equally)
  • Conductive deafness = Bone conduction > Air conduction (“Rinne’s negative” – again best to avoid this term and describe the result)

Talasalitaan: Hx and PE

Description and Instructions for History Taking and Physical Examination

English Filipino
ache, pain sakit
bald kalbo, panot
bite kagat
breathe hinga
bruise pasa
circumcised tuli
colds sipon
colic hilab
cough ubo
diarrhea magkurso
dull pain parang maga, ngalay
fever lagnat, sinat
flu trangkaso
hemorrhoids almuranas
hernia luslos
intermittent pain papitik-pitik, pasumpong-sumpong, pasundot-sundot
itch kati
mole taling, nunal
mucus uhog
nausea nakakasuka, nakakaduwal
numb ngalay
pus nana
sharp pain parang tinutusok, sinasaksak
snore hilik
ulcers singaw
vomit suka
wart kulugo
wound sugat

Physical Examination: Pulmonary Examination

Physical Examination of the Lungs

PermissionMagandang umaga/tanghali/gabi po, ako po si <Your Name Here>. Isa po akong estudyante ng <Your School Here>. Narito po tayo ngayon upang bigyan kayo ng eksaminasyon sa inyong baga. Ok lang po ba iyon sa inyo?

InspectionMagsimula na po tayo. Titingnan ko lang po muna ang inyong paghinga, iuusog ko lang po ang gown ninyo, ok lang po ba iyon?

PalpationOk po. Ok lang po ba kayong hawakan para po sa eksaminasyon?

  • Chest expansion/Lung excursion: Hinga lang pong malalim. Ok na po.
  • Tactile fremitus: Sa bawat lapat ko po ng aking kamay sa inyong likod, sabihin niyo po ang “Tres tres.” Ok po ba? Subukan po natin. (If fremitus is faint: Pakilakasan lang po.)

 PercussionOk po, susunod naman po ay tatapikin ko po kayo sa likod, ok lang po ba?

  • Extent of diaphragmatic excursion: Sige po, hinga lang po tayong malalim. Buga na po.

AuscultationPakikinggan ko na po ang inyong baga, ok lang po ba?

[TAKE NOTE] Anterior chest for female (near breast area): Ok lang po bang pakitabi/pakihawi na lang po ng inyong dibdib?

Talasalitaan

English Filipino
breathe hinga
chest, bosom dibdib
cough ubo
lung baga