Pick ‘n’ Mix – Week 2 March 2023
We are really grateful to Trudie Pestell for sharing Pick ‘n’ Mix: a fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department.
Each week we will bring you some clinical pearls to add to your knowledge and understanding with links to other resources as well as an OSCE of the week.
The case of an oozing ear
The beginning:
A 56-year-old female with diabetes attends ED with a 2-week history of ear pain that has been unresponsive to antibiotics. It has more recently started discharging, she feels generally unwell and she reports feeling that her facial muscles are weak and she has difficulty swallowing.
OSCE of the Week – Thyroid Examination
Introduction
“Hello, my name is Phil. I am one of the medical students”.
“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”
“Are you comfortable? Do you need any pain relief or a drink?”
“I have been asked to examine you to assess whether your thyroid maybe causing any of your symptoms. This will involve me: examining your hands; face; neck; legs and reflexes. Is this ok with you?”
“I will talk out loud as we go”
“If at any time you want me to stop or you are in pain, let me know”
Brief history
“Can you briefly tell me why you have come to hospital?”
General inspection
“I am looking at the patient for signs of…”
- Flushing
- Loss of outer ⅓ eyebrow
- Tremor
- Obvious eye signs
- Neck swelling or scars around the neck
- Body habitus
Hands and other observations
“I am feeling for…”
- warmth
- clamminess
- the pulse (rate; rhythm; quality)
“I am looking for…”
- Tremor (hold hands out)
- Nail changes (onycholysis; thyroid acropachy)
- Palmar erythema
- Thick coarse skin
Other observations
- BP
- Resp Rate
- Sats
- Temperature
- Blood glucose
Face
“I am looking for…”
- Eyebrow: loss of outer ⅓
- Eye signs:
- lid retraction
- Lid lag on downward gaze (“Please look down for me“)
- Proptosis (“I will assess by looking from the side and down”)
- Eye movements: “Please follow my finger with your eyes and tell me if you get any double vision.”
Neck
Inspection
“I am looking at the neck from the front and side for masses/swellings or scars”
Palpation
“I need to feel your neck:“
- Trachea central?
- Masses: size; shape; nodule; diffuse
- “Please can you take a sip of water and swallow” (thyroid masses rises on swallow)
- “Please can you stick out you tongue” (thyroglossal cysts will move on sticking the tongue out)
- I am just going to feel for any other lumps in the neck (Lymph nodes)
Percussion
“I am going to tap along your breast bone (dull on percussion suggests a retrosternal goitre)
Auscultation
“I am just going to listen to the neck” (assessing for bruits)
Lower limb reflexes
“Lastly I would like to…”
- Look at your shins for any evidence of pretibial myxoedema
- Test your reflexes
Close
“Thank you. That is the end of the examination”
“In summary my working differential diagnosis is…”
“To complete my examination I would like to do the following investigations/tests…”
“Does that sound reasonable to you? Do you have any questions or concerns?”
Additional resources
- Thyroid exam 1, 2
- Neck lumps 1, 2, 3
- Hyperthyroidism and thyrotoxicosis 1, 2
- Hypothyroidism
- Thyroid function tests