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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.     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.
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