CLIN SKILLS: Thyroid + Diabetes Examination

Question 1

examination for dehydration

Answer 1

• general inspection: consciousness, weight
• vital signs: watch for tachycardia, hypotension (inc. postural - BP drops by >20 mmHg, HR increases by >30 bpm)
• peripheral: decreased cap refill, decreased skin turgor, dry mucous membranes, sunken eyes, lowered JVP

Question 2

general structure of hypo/hyperthyroid exam

Answer 2

• intro + hand hygiene
• general inspection
• vital signs
• inspection: hands, arms, face, eyes
• neck: inspection, palpation, percussion, auscultation
• legs
• chest (heart + lungs)

Question 3

general inspection for hyperthyroidism

Answer 3

• body build (weight loss)
• frightened facies (anxiety)
• heat intolerance
• goitre

Question 4

general inspection for hypothyroidism

Answer 4

• body build (weight gain)
• depressed mood
• cold intolerance
• goitre
• slowed thinking
• hoarse voice
• deafness
• slow, nasal speech
• puffy face

Question 5

what to look out for in vital signs for hypo vs hyperthyroid

Answer 5

• hyper: tachycardia/fibrillation
• hypo: bradycardia

Question 6

hands inspection in hyperthyroid

Answer 6

• onycholysis
• clubbing (thyroid acropachy) - Graves disease
• palmar erythema

Question 7

hands inspection in hypothyroid

Answer 7

• palmar pallor (creases)
• peripheral cyanosis
• dry, brittle nails
• yellow skin discolouration
• tendon xanthomata

Question 8

arms inspection in hyperthyroid

Answer 8

• warm/sweaty skin
• fine tremor
• fast reflexes
• proximal myopathy: resisted shoulder abduction (push above the elbow)

Question 9

arms inspection in hypothyroid

Answer 9

• ccool/dry skin
• carpal tunnel syndrome (tinel + phalen’s sign)
• slow reflexes
• proximal myopathy: resisted shoulder abduction (push above the elbow)

Question 10

face inspection for hyperthyroid

Answer 10

• warm/sweaty skin

Question 11

face inspection for hypothyroid

Answer 11

• cool/dry skin
• skin discolouration
• thickened skin
• scalp hair thinning
• mouth: tongue swelling

Question 12

eye inspection for hyperthyroid

Answer 12

• exophthalmos (proptosis)- graves disease: eye protrudes anterior to eyebrow (look from above)
• lid retraction (thyroid stare): upper lid should cover some of the iris
• lid lag: eyelid should down at same pace as eyeball (get them to follow your finger as it moves down)
• if they have exopthalmos, check for complications: chemosis (conjunctival oedema), conjunctivitis, corneal ulcers, ophthalmoplegia, anhidrosis

Question 13

eye exam for hypothyroid

Answer 13

• eyebrow loss (outer 1/3)
• puffiness (periorbital oedema)
• xanthelasma

Question 14

neck inspection for both hyper/hypothyroid

Answer 14

• look for thyroid gland: may be just seen in a thin person, see if it looks enlarged
• ask Pt to hold water in mouth and then swallow - should normally move up on swallowing
• thyroglossal cyst: mass will rise on sticking tongue out - if seen, comment on shape + size
• scars: thyroidectomy
• dilated neck veins (retrosternal extension of goitre)
• redness: thyroiditis
• pemberton’s sign: raise hands above head and hold for 1 min

Question 15

neck palpation for both hyper/hypothyroid

Answer 15

• stand behind Pt, head tilted up slightly (feel slightly lateral to midline)
• size: can you feel lower border
• shape: regular or irregular? Any nodules?
• consistency: should be soft
• tenderness: thyroiditis
• mobility: palpate whilst swallowing water - mobility can be lost w/ carcinoma
• cervical L/N
• move to the front and repeat thyroid palpation
• tracheal deviation: may be displaced in retrosternal goitre

Question 16

percussion for both hyper/hypothyroid

Answer 16

• percuss over manubrium (should be resonant): checks for retrosternal extension of goitre

Question 17

auscultation for both hyper/hypothyroid

Answer 17

• get Pt to hold breath and listen over each lobe for bruits: hyperthyroidism + graves disease

Question 18

legs inspection for hyperthyroid

Answer 18

• pretibial myxoedema (red, non-pitting) - graves disease
• roximal myopathy: sit down, cross arms over chest and stand up
• hyperreflexia (achilles)

Question 19

legs inspection for hypothyroid

Answer 19

• non-pitting oedema
• slow reflexes (achilles)

Question 20

chest examination for hyper vs hypothyroid

Answer 20

• hyperthyroid: auscultate for systolic murmur and CHF
• hypothyroid: auscultate and percuss for pericardial + pleural effusion

Question 21

general structure of diabetes exam

Answer 21

• intro + hand hygiene
• general inspection
• weight assessment
• viral signs
• inspection: arms/hands, eyes, mouth, neck, chest, abdomen
• legs: inspection, palpation, reflexes, sensation

Question 22

general inspection for diabetes exam

Answer 22

• hydration (esp. T1DM)
• consciousness (DKA)
• characteristic facial appearance (e.g. Cushing’s syndrome or acromegaly which can cause secondary diabetes)
• pigmentation (haemochromatosis and acanthosis nigricans)

Question 23

3 ways to assess weight

Answer 23

• BMI = weight (kg) ÷ height (m)2
• waist circumference = midpoint between costal margin and iliac crest
• waist – Hip Ratio (WHR) = waist circumference (cm) ÷ hip circumference (cm) (hip = widest part around the buttocks)

Question 24

arm/hand inspection for diabetes

Answer 24

• dehydration: tissue turgor + cap refill
• acanthosis nigricans: dark patches under armpits

Question 25

eye inspection for diabetes

Answer 25

- visual acuity - cararacts - fundoscopy for retinopathy - eye movements for nerve palsies

Question 26

mouth inspection for diabetes

Answer 26

- dental hygiene + candidiasis - sweet-smelling breath (DKA)

Question 27

neck inspection for diabetes

Answer 27

- carotid arteries – auscultate for bruits - acanthosis nigricans

Question 28

chest examination for diabetes

Answer 28

- lungs for signs of infection - heart for signs of heart disease

Question 29

abdomen examination for diabetes

Answer 29

- skin – injection sites for signs of infection, fat hypertrophy and fat atrophy - liver – palpate/percuss for enlargement due to Metabolic Associated Fatty Liver Disease (MAFLD) or haemochromatosis

Question 30

legs inspection for diabetes

Answer 30

- necrobiosis (symmetrical plaques on shins with yellow appearance and waxy feel) - ulcers - hair loss - skin discolouration - fungal infections (look between the toes) - muscle wasting - joint deformity

Question 31

legs palpation for diabetes

Answer 31

- temperature - capillary refill - pulses: femoral, popliteal, posterior tibial, dorsalis pedis

Question 32

lower limb reflexes for diabetes

Answer 32

- ankle jerk most commonly, if abnormal then all lower limb reflexes

Question 33

lower limb sensation for diabetes

Answer 33

- vibration (e.g. with 128 hz tuning fork) - pressure (light touch) sensation (e.g. with 10g monofilament) - pain or temperature - proprioception