Thyroid and Breast Examination Flashcards
When meeting the patient, which can be performed during the introductions we must look at the patient and the area surrounding the patient. Why is this?
- can tell us a lot about the patients condition
- patient specific = general physique, body language, clothing attire and voice (in hyperthyroidism they may be anxious, fidgety or irritable)
- surrounding specific = ECG machine, walking aids, medications
What is thyroid acropachy?
- a rare complication of autoimmune thyroid disease, specifically hyperthyroidism
- caused by periosteal phalangeal bone overgrowth
- characterised by nail clubbing, swelling of digits and toes
What is onycholysis?
- condition in which the distal nail body separates from the nail bed, commonly occurs on the fourth fingers
- occurs in hyperthyroidism
Onycholysis is condition in which the distal nail body separates from the nail bed, commonly occurs on the fourth fingers that occurs in hyperthyroidism. Which form of hyperthyroidism is onycholysis common in?
- Graves’ disease (immune system disorder)
- results in the overproduction of thyroid hormones
Why do we need to assess for a tremor using a piece of paper that is place on patients hands with palms facing down in a thyroid examination?
- hyperthyroidism that increase metabolism and anxiety
- a tremor is the result
When assessing pulse in a thyroid examination, what would we expect to see in the following:
- hyperthyroidism
- hypothyroidism
- hyperthyroidism = tachycardia and/or arrhythmia (atrial fibrillation)
- hypothyroidism = bradycardia
In addition to assessing pulse and looking for the following:
- hyperthyroidism = tachycardia and/or arrhythmia (atrial fibrillation)
- hypothyroidism = bradycardia
What other cardiac assessment could we do by the side of the bed?
- perform an ECG
When assessing temperature in a thyroid examination what would we expect to see in the following:
- hyperthyroidism
- hypothyroidism
- hyperthyroidism = warm intolerance
- hypothyroidism = cold intolerance
When examining a patients face during a thyroid examination, would hyper or hypothyroidism cause the following:
- facial puffiness
- periorbital oedema
- flushed checks
- facial puffiness (hypothyroidism)
- periorbital oedema (hypothyroidism)
- flushed checks (hyperthyroidism)
When examining a patients skin during a thyroid examination, would hyper or hypothyroidism cause the following:
- hyperthyroidism
- hypothyroidism
- hyperthyroidism = sweating
- hypothyroidism = dry skin
When examining a patients eyes during a thyroid examination, would we examine just from the front?
- no
- from the front, above and the side
When examining a patients eyes during a thyroid examination, would we examine from the front, side and above. One thing we may see is eyelid retraction, common in Graves disease, a form of hypothyroidism. What is eyelid retraction?
- abnormal eyelid position, where the eyelid margin is higher (upper lid) or lower
(bottom lid) than normal - can lead to incomplete closure of the eyelids causing dry, sore and irritated light sensitive eyes
Exophthalmos, which is protrusion of the eye common in hypo or hyperthyroidism?
- common in Graves disease
- form of hyperthyroidism
- muscles and extra-orbital fat are increased
- common in Graves disease
- form of hyperthyroidism
- muscles and extra-orbital fat are increased
Is corneal inflammation, which is inflammation of the sclera that cause cause conjunctivitis, more common in hyper or hypothyroism?
- hyperthyroidism
Exophthalmos, which is protrusion of the eye due to muscles and extra-orbital fat being increased and corneal inflammation can be cause by hyperthyroidism. How can we assess if eye movement is causing pain?
- ask patient to keep head still and following your finger
- make the shape of the letter H
Lid lag is common in hyperthyroidism. What is lid lag and how do we assess this?
- patient asked to look at your finger and then move finger down quickly
- patient asked to keep head still and follow your finger down
- if eyelids are slow to response compared to the eyes this is called lid lag
How common is thyroid eye disease in patients with autoimmune thyroid disease?
- 20% of patients
- increased risk if smoker
What is a goitre and how can this be treated?
- enlarged thyroid hormone
- hormone therapy can be used
- generally surgery
- ask patient to raise their head to look at sternum and thyroid area
Why would we ask a patient to swallow some water during a thyroid examination?
- look at their neck when they swallow
- may identify abnormal thyroid, for example a goiter or thyroglossal cyst will move up when swallowing
- cancer or lymph node would move very little
When examining a patients thyroid we would stand behind the patient. What is it important to ensure?
- ask the patient to vocalise any pain they are experiencing
- locate the thyroid (adams apple) and cricoid cartilage and sternal notch
- thyroid is between these landmarks
Label the thyroid gland below using the following labels:
isthmus right lobe of thyroid gland left lobe of thyroid gland trachea cricoid cartilage thyroid cartilage
1 - cricoid cartilage 2 - right lobe of thyroid gland 3 - trachea 4 - isthmus 5 - left lobe of thyroid gland 6 - thyroid cartilage
Label the lymph nodes that need to be examined during a thyroid examination using the labels below:
Submental Submandibular Pre-auricular Post-auricular Superficial cervical Deep cervical Posterior cervical Supraclavicular
1 - Post-auricular 2 - Superficial cervical 3 - Deep cervical 4 - Posterior cervical 5 - Supraclavicular 6 - Pre-auricular 7 - Submental 8 - Submandibular
When examining the thyroid we would need to examine the shins for pretibial myxoedema. What is pretibial myxoedema?
- a form of diffuse mucinosis, where there is an accumulation of excess glycosaminoglycans in the dermis and subcutis of the skin
- presents itself as a waxy, discoloured induration of the skin on the anterior aspect of the lower legs (pre-tibial region)
- may present Graves’ disease (hyperthyroidism)
In a breast examination, the patient should be positioned on the edge of the bed. What is then the 4 step process to ask the patient to follow?
1st = ask patient to place their hand on the lap 2nd = ask the patient to place their hands on their hips (contracts the pecs) 3rd = ask patient to place their hand on the back of their head 4th = ask patient to place their hand on the lap and lean forward
In a breast examination, the patient should be positioned on the edge of the bed. Then the 4 step process to ask the patient to follow is below:
1st = ask patient to place their hand on the lap 2nd = ask the patient to place their hands on their hips (contracts the pecs) 3rd = ask patient to place their hand on the back of their head 4th = ask patient to place their hand on the lap and lean forward
During each of these steps what are we inspecting for?
- scars
- asymmetry
- skin changes
- nipple changes
- nipple discharge
During a breast examination, what are 2 changes that can occur on the skin of breast tissue?
- mastitis (inflammation of breast tissue, may be due to infection)
- peau d’orange (ligaments of cooper may be pathological)
Once you have inspected the patient what would be the next step of the breast examination?
- palpation
- to do this ask the patient to lie down at 45 degree angle
- arm of breast being examined should be placed behind their head
- repeat on opposite side
During the breast examination what is the process for palpating the breast tissue?
- use 3 fingers
- examine all 4 quadrants of the breast, the axillary tail and look for nipple discharge
- look underneath the breast
During the breast examination the process for palpating the breast tissue includes:
- use 3 fingers
- examine all 4 quadrants of the breast, the axillary tail and look for nipple discharge
- look underneath the breast
What would be a systematic process for completing this?
- start close to the nipple and work clockwise out until completed
When looking for nipple discharge, if the patient has described nipple discharge and they have shown you this discharge, what 4 things are we looking for?
- colour (clear can be carcinoma, puss may be infection, milk may be prolactinoma)
- consistency
- volume
- odour
Following the breast and nipple palpation and inspection, we would inspect the lymph nodes. How would we position the patient to examine the lymph nodes?
- put on gloves if not already on
- patient seated on the edge of the bed
- patient places right/left arm on forearm of your arm and you take the weight
- use opposite had to palpate the lymph nodes
- repeat on opposite side
When examining the axillary lymph nodes during a breast examination, where would we generally start?
- behind the lateral edge of the pectoralis muscle (anterior axillary border)
When examining the axillary lymph nodes during a breast examination, we would generally start behind the lateral edge of the pectoralis muscle (anterior axillary border). What other lymph nodes are we feeling for in the axillary and under arm area? Label them in the image below, using these labels:
lateral central infraclavicular subscapula pectoral
1 = central 2 = lateral 3 = pectoral 4 = infraclavicular 5 = subscapula
