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1 Inspection 69 Introduction, consent, position patient sitting on a chair (with space behind), ad- equately expose neck. Inspect from front and sides for any obvious goitres or swell- ings, scars, signs of hypo-/hyperthyroidism. History and examination 2 Swallow test Standing in front of the patient ask them to “sip water…hold in
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     H   i   s   t   o   r   y   a   n   d   e   x   a   m   i   n   a   t   i   o   n 69 1  Inspection Introduction, consent, position patient sitting on a chair (with space behind), ad-equately expose neck. Inspect from front and sides for any obvious goitres or swell-ings, scars, signs of hypo-/hyperthyroidism. 2  Swallow test Standing in front of the patient ask them to “sip water…hold in your mouth …and swallow” to see if any midline swelling moves up on swallowing. 4  Palpation Stand behind the patient.  ã Proptosis:  (p 211 ) whilst standing behind the patient ask them to tilt their head back slightly; this will give you a better view to assess any proptosis than when assessing the other aspects of eye pathology from front on, as in 8 )  ã The thyroid gland:  ask the patient “any pain?” Place middle 3  fingers of either hand along midline below chin and ‘walk down’ to thyroid. Assess any enlarge-ment/ nodules  ã Swallow test:  repeat as before, now palpating; attempt to ‘get under’ the lump  ã Lymph nodes:  examine lymph nodes of head and neck (p 60 ). Stand in front of the patient  ã Trachea:  palpate for tracheal deviation from the midline. 3  Tongue protrusion test Ask patient to stick out your tongue . Does the lump move up?  If evidence favours lump not arising from thyroid, examine lump like any other (p  596  ) 5  Percussion Percuss the sternum for dullness of retrosternal extension of a goitre. 7  Hands ã  Inspect:  for thyroid acropachy (clubbing) and palmar erythema  ã Temperature  ã Pulse:  rate and rhythm  ã Fine tremor:  ask patient to “hold hands out”, place sheet of paper over out-stretched hands to help. 6  Auscultation Listen over the goitre for a bruit. 8  Eyes ã Exophthalmos:  inspect for lid retraction and proptosis (p 211 )  ã Lid lag:  ask patient to “look down following finger” as you move your finger from a point above the eye to below  ã Eye movements:  Ask patient to follow your finger, keeping their head still, as you make an ‘H’ shape. Any double vision? 9  Completion Ask patient to stand up from the chair to assess for proximal myopathy, look for pretibial myxoedema, test ankle reflexes (ask patient to face away from you with knee resting on chair). Thank patient and wash hands.  Common haematology values  If outside this range, consult: Haemoglobin men:  130 – 180 g/Lp 318  women:  115 – 160 g/Lp 318 Mean cell volume, MCV  76 – 96 fL   p 320 ;  p 326 Platelets  150 – 400   ≈   10 9  /Lp 358 White cells (total)  4 – 11   ≈   10 9  /Lp 324 neutrophils  40 – 75 %p 324 lymphocytes  20 – 45 %p 324 eosinophils  1 – 6 %p 324 Blood gases pH  7 . 35 – 7 . 45 p 684 P  a O 2  > 10 . 6 kPa( 75 – 100 mmHg)p 684 P  a CO 2  4 . 7 – 6 kPa( 35 – 45 mmHg)p 684 Base excess  ±   2 mmol/L  p684 U&E S  (urea and electrolytes)  If outside this range, consult: Sodium  135 – 145 mmol/L  p686 Potassium  3 . 5 – 5 mmol/L  p688 Creatinine  70 – 150 µ mol/L  p298–301 Urea  2 . 5 – 6 . 7 mmol/L  p298–301 e GFR  > 90 p683 LFT S  (liver function tests) Bilirubin  3 – 17 µ mol/L  p250, p258 Alanine aminotransferase, ALT  5 – 35 i U  /L  p250, p258 Aspartate transaminase, AST  5 – 35 i U  /L  p250, p258 Alkaline phosphatase, ALP  30 – 150 i U  /L ( non-pregnant adults ) p250, p258 Albumin  35 – 50 g/L  p700 Protein (total)  60 – 80 g/L  p700 Cardiac enzymes Troponin T  < 0 . 1 µ g/L  p113 Creatine kinase  25 – 195 i U  /L  p113 Lactate dehydrogenase, LDH  70 – 250 i U  /L  p113 Lipids and other biochemical values Cholesterol  < 5 mmol/L desired   p704 Triglycerides  0 . 5 – 1 . 9 mmol/L  p704 Amylase  0 – 180   Somogyi    U  /dL  p638 C-reactive protein, CRP  < 10 mg/L  p700 Calcium (total)  2 . 12 – 2 . 65 mmol/L  p690 Glucose, fasting  3 . 5 – 5 . 5 mmol/L  p198 Prostate-specific antigen, PSA  0 – 4 ng/mL  p538 T 4  (total thyroxine)  70 – 140 mmol/L  p208 Thyroid stimulating hormone, TSH  0 . 5 – 5 . 7 m U  /L  p208 For all other reference intervals, see p 769  – 71  Reading tests  Hold this chart (well-illuminated) 30 cm away, and record the smallest type read (eg N12  left eye, N6  right eye, spectacles worn) or object named accurately. all the brightest gems N. 24 He moved N. 48 faster and faster towards the N. 18 ever-growing bucket of lost hopes;had there been just one more year N. 14 of peace the battalion would have madea floating system of perpetual drainage. N. 12A silent fall of immense snow came near oilyremains of the recently eaten supper on the table.N. 10 We drove on in our old sunless walnut. Presentlyclassical eggs ticked in the new afternoon shadows. N. 8 We were instructed by my cousin Jasper not to exercise by countryhouse visiting unless accompanied by thirteen geese or gangsters. N. 6 The modern American did not prevail over the pair of redundant bronze puppies.The worn-out principle is a bad omen which I am never glad to ransom in August. N. 5  OXFORD HANDBOOK OF CLINICALMEDICINE


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