Thyroid Flashcards
(14 cards)
Inspection
أساسيات
Proper exposure: whole head & neck up to supra-clavicular fossa (from the nipple upwards)
اقف قدام العيان واعمل extension
للرقبة
*Pizzillo’s method: If patient obese with short neck, ask him
to put his hand behind his neck.
هعمل الفحص ازاي بقي
ask the patient to swallow (for thyroid swelling) then to protrude his tongue for thyroglossal cyst ( من اسمها ماسكة في اللسان)and observe
the movement …
قول للمريض ابلع ريقك وبعدين طلع لسانك
Inspection
7s
*Single
*Site
*Size
*Shape
*Surface.
*Skin over
*Special tests.
Number:1- Single Swelling
2- Site: Lower part of front of neck in the muscular triangle
(3 hyoid, sterno+omo +thyro )+Sternothyroid
3-Shape:
* If diffuse (U shaped or butterfly)
* If localized (irregular or oval)
4-Size: Variable in (cm x cm)
قيس طول في عرض بالمازورة
5-Surface:
* Smooth if 1ry toxic goiter.
* Nodular if: 2ry toxic goiter or SNG.
* Irregular if malignancy
6- Skin over:
* Dilated veins if retro-sternal goitre.
* Scars if previous thyroidectomy هتلاقيها بعرض الرقبة
or Biopsy
سؤال طب لما هو عمل thyroidectomy اومال في gitre ليه؟ عشان ممكن يبقي العملية كانت subtotal او lobar
* Redness if inflammation.
* Ulceration if malignancy.
* Discharge: thyroglossal cyst
وحصل لها fistula وطااااخ طفحت
7- Special signs
A. Pulsation: look tangentially : may be بص مماسيا للعيان
* Expansile at the upper pole as in 1ry toxic goitre.(يعني highly vascular)
* Transmitted if over carotid artery.
ودول هتفرق بينهم في palpation
B. Move up & down with deglutition as goiter.
C- lower edge هنشوفها وهو بيبلع
We comment on lower pole seen or not to exclude retro-sternal extension : ill-defined edge.
D-Pamberton sign:
لو العيان رفع ايده فوق مستوي shoulder هيزرق ونفسه يضايقه يبقي ده thyroglossal expansion
Palpation
زي أي swelling
SCIM, 2t
1- Temperature: بضهر ايدك
حط ايدك علي forhead ثم علي الغدة
عشان تشوف الحرارة
2- Tenderness:
حركة ببطن الايد وعيني علي وش العيان
3–surface: اقف ورا العيان( الطريقة الكلاسيك)
A-Examination of lobes:
اقف ورا العيان …كأنك بتخنقه بايديك الاتنين…الصباع الكبير ورا و palm of hand قدام…وميل راسه ناحية الجهة اللي عاوز تفحصها وثبت بالايد العكسية الناحية التانية وحس بنفس الايد في نفس الجهة..
B-Examination of lower border:
اقف ورا العيان وب radial sides of indices
وقل له يبلع ريقه
هتقول هو well find ولا ill find
C- Examination of isthmus:
*اقف ورا العيان
*ثبت راسه بايدك
*ميل راسه لقدام
* باصبع السبابة بالايد التانية حطها في midline بتاع الترقية وحس
*قول له يبلع
Palpation
4-Consistency
عشان متنساش:
( In 1ry thyrotoxicosis)الشفة..soft
غضروف الانف..firm(2ry)
*..(in malignancies or calcification)Hard…..عضم forehead..
5- Deep structures
A-muscle : sternomastoid muscle
هتمسكها ازاي؟
الصباعين index,middle من قدام و thumb من ورا…
حط الصباعين في middle line في suprasternal notch وحركها laterally وامسك..
ميل راس العيان علي جنب واعمل pinch للعضلة…not fixed
B-carotid vessesls:
بيتحس علي anterior border of sternomastoid
*الطبيعي ..in place with equal volume
*لو لقيته bilateral displaced backward بس موجوديبقي benign
*لو لقيته abscent في ناحية يبقي malignant ودي اسمها Berry’s sign
C-trachea: تتحفص من قدام
هتشوف المكان والحركة
*Central or shifted
لأن اغلبهم asymmetrical هتلاقيها shifted ناحية lobe الاصغر
حط index الاتنين في suprasternal
notch .
*Mobility (attached to swelling or not)
ثبت thyroid cartilage وحرك goitre يمين وشمال وفوق وتحت…
لو بيتحرك يبقي الحمد لله مش infiltration
D-lns… Upper &lower cervical
*Upper deep cervical: upper part of sternomastoid
*Middle deep cervical: middle part of sternomastoid .
*Lower deep cervical:
تتفحص في مكانين
Lowe part of sternomastoid + supraclavicular fossa.
6-Skin
اعمل pinch للجلد او sliding
هتلاقيه not fixed
7-Lns تتفحص من قدام
Pretracheal(في suprasternal notch)
Prelaryngealeal ( عند cricothyroid membrane ده)موجود بين thyroid cartilage و cricoid cartilage)
Pretracheal (عند suprasternal notch )
بيتحس ب middle ,index fingers
Percussion
:
Direct percussion on upper 1/3 of sternum;
Normally it is resonant ,if dullness in retrosternal
goiter.
Auscultation
(Systolic murmur)
Bruit over the lateral lobes in hyperthyroidism (on
sup. thyroidal artery )
وممكن تبقي abscent in malignancy
Eye signs
Due to sympathetic overtone
1-Dalrymple’s sign: rim of sclera between the cornea &upper eye lid
2-Stellwag sign: مش بيبربش كتير
staring look+ infrequent blinking (الطبيعي من ٥-٨ مرات في الدقيقة)
3-Joffroy sign: lack of forehead wrinkling on looking
upward with flexed head
ثبت راسه من فوق وقوله بص للسقف او حرك صباعك من تحت لفوق
الطبيعي انه يحصل تجاعيد لمقدمة الراس عشان يوسع محيط الرؤية…لكن هو هنا مش محتاج عشان اصلا عنده dalrymle فمحيط الرؤية عنده واسع لوحده
4-Von Grafe’s sign: المقبرة تحت
lid lag on looking down
ثبت راسه وحط صباعك لفوق ونزل صباعك وخليه يمشي بعينه مع صباعك …الطبيعي ان العين وupper eye lid ينزلو مع بعض لتحت لكن هنا هو عشان عنده upper eyelid retraction فعينه هتنزل لكن ال upper eyelid لا…فهيحصل lid lag هتتعلق
5-Mobius sign: lack of convergence on looking to near object due to weak
medial recti muscle
حرك صباعك من بعيد لقدام
6-Tests of exophthalmos:
بصة من ورا..بصة من الجنب…حركة بالمسطرة (نفر NFR)
*Ruler test
اقف جنب العيان وهات مسطرة وخليها تلمس superior , inferior orbital margins هتلاقي المسطرة لامسة الcornea
*Naffziger test:
اقف ورا العيان واتني راسه لورا شوية بشوية حتي تأتي اللحظة الحاسمة وتتلاقي عيناك مع القرنية to see the level supra and infra orbital
ridge with cornea.
• Frazer’s test:
اقف جنب المريض وقله اقفل عينك ..الطبيعي هتشوف sulcus مابين eyelid و superior orbital margin..هنا هتلاقيه shallow خالص او مش موجود
to see the obliteration of sulcus of orbital margin with slight closed eye.
7-Rosenbach sign:
هتلاقي upper eye lid tremors
لما يقفل عينه..
وبالمرة بقي العيان ده عنده ٣ اماكن فيهم tremors
(Eye lid, hand ,tongue)
تقيس degree ازاي؟
عن طريق:
1-opthalmometer
2-Ruler
ازاي؟
قيس المسافة بين lateral orbital margin و apex of cornea
(الطبيعي من ١٥-١٧مل)
اسئلة من طرف المعلقة
1-What is meant by sleeping pulse?
* It is clinical confirmation of rapid pulse even during sleep so it excludes anxiety.
2- Why are vital signs stable in case of toxicity during examination?
* Because, the patient under treatment e.g. Indral.
3-What is the cause of unequal pulse in case of goitre?
* If retro-sternal extension (R.S.E.)
4- What are other causes of water hammer pulse? see general chapter
5- How can you diagnose under-built?
* Prominent maxilla & zygoma
* Muscle bulk.
* Fold of skin at biceps & triceps muscles.
اسئلة من طرف المعلقة
6-Which type of malignancy characterized by bone metastasis?
* Follicular carcinoma.
7-What is meant by exophthalmos?
* Actual protrusion of eye ball.
8- What is the cause of exophthalmos?
* Unknown but may be E.P.S. (Exophthalmos producing substance)
9-What are the causes of unilateral exophthalmos?
* Orbital cellulites.
* Orbital neoplasm.
* Orbital aneurysm i.e. ophthalmic artery aneurysm
* Cavernous sinus thrombosis.
* A-V fistula between ICA & cavernous sinus
* Neurofibromatosis of optic nerve
10- What are the causes of pulsating exophthalmos?
* Orbital aneurysm & A-V fistula between I.C.A. & cavernous sinus
اسئلة من طرف المعلقة
11-What is the difference between true & apparent?
* True exophthalmos = rim of sclera above & below the cornea
* False exophthalmos = rim of sclera above the cornea (Upper eye lid retraction)
12- What is DD between fine & flapping tremors?
* Fine tremors: Due to increase metabolites leading to irritation of nerve ending leading to tremors of small joints of hand.
* Flapping tremors: Due to increase Toxins leading to Irritation of extra-pyramidal tract leading to tremors of wrist joint of hand
13- What is meant by pre-tibial myxedema?
هي مش myxedema ولا حاجة..ده اسم غلط
* Pretibial myxoedema presents with a swollen and lumpy appearance over the shins and sometimes also affects the feet. The skin may be discolored pink or purple, with prominent hair follicles.
* This is known as ‘peau d’orange’ (orange-peel) appearance. It may instead look warty or ‘verrucous’.
* It is due to deposition of main at skin.
* Associated with clubbing fingers& toes
14- What is meant by mediastinal syndrome?
*brassy cough
سعال مستمر ينتهي بقيئ
*congested neck veins.
* Dyspnea
15- What are the causes of liver enlargement?
* Thyrotoxic HF.
* Auto-immune [1ry toxic goitre & Hashimoto’s thyroiditis]
* Thyroid lymphoma.
* Liver metastasis.
16- What are causes of spleen enlargement?
* Auto-immune [1ry toxic goitre & Hashimoto’s thyroiditis]
* Thyroid lymphoma
من طرف المعلقة
17-What are the causes of painful goitre ?
* Malignancy , acute thyroiditis & hemorrhage in cyst.
18-Why is dysphagia as pressure symptom being rare ?
* Because oesophagus is a muscular tube.
19-What are other causes of Horner’s syndrome ?
* Compression by goitre, pan-cost tumor & carotid aneurysm.
* Complication after cervical sympathectomy.
* Injury of lower part of brachial plexus.
20-What are the causes of loss of weight inspite of good appetite ?
* Toxic goiter,
* Uncontrolled D.M.,
* Parasitic infestation (hydatid cyst)
* Mal-absorption syndrome.
21-What are the causes of polyuria in case of toxic goitre ?
* Secondary DM leading to glucosuria
* Increased Metabolic rate
* Increased COP leading to increased Renal blood flow leading to increased GFR.
* ncreased Intake of water 2ry to polyphagia
22-Why is pain in malignancy of thyroid referred to Ear ?
* Because of ear has same dermatomal supply i.e. Arnold nerve
23-What are the types of biopsy done in case of goitre ?
* FNAC, True cut biopsy & excisional biopsy.
24- What are symptoms of Pendred’s syndrome ?
Goitre, dwarfism & deafness.
من طرف المعلقة
25-Why does Goitre move up & down with deglutition?
* Because it is included in pre-tracheal fascia:
* NB.: Attachment of pre-tracheal fascia:
* Above: Oblique line of thyroid cartilage & hyoid bone
* Below: Superior mediastinum.
* On each side: carotid sheath
26-When is Goitre unable to move up & down with deglutition?
* Malignancy
* Retrosternal extension (R.S.E.)
* Huge in size.
* Riedel’s thyroiditis (due to fibrosis)
27-Which Swellings move up with protrusion of tongue?
* Thyroglossal cyst.
* Sub-hyoid bursitis.
28-What are other Swellings move up & down with deglutition?
* Goitre.
* Thyroglossal cyst.
* Pre-tracheal L.Ns
* Pre-laryngeal L.Ns.
* Sub-hyoid bursa.
* Laryngocele.
29- What are the causes of Hard goitre?
* Malignancy.
* Riedel’s thyroiditis.حصل fibrosis
* Calcified SNG.
* Tense cyst
* Tense cyst
30- What is the Anatomical site of Carotid artery?
* It felt Against carotid tubercle of C6.
31- What is the 1st L.Ns felt Clinically in Malignancy?
* Pre-laryngeal L.Ns
32- What is the value of Kocher’s test?
* The value is preoperative consent (from patient) for tracheostomy.
33- What are the causes of dullness on Manubrium sterni?
* Retrosternal goitre.
* Ectopic thyroid tissue.
* Pre-tracheal L.Ns.
34-What are the complications of SNG?
* Carcinoma “follicular type 3%”
* 2ry toxic goitre.
* Hemorrhage on cyst.
* Calcification.
* Retrosternal extension
35-Manifestation of malignancy
* Swelling is THIEF (Tender, Hard, Irregular, Enlarged & Fixed)
* Berry’s sign (Absent carotid pulsation)
* L.Ns (Enlarged, hard, 1st mobile then fixed)
