How to conduct thyroid examination an OSCE guide

Local Examination

1. Expose the neck adequately.

2. Ensure adequate lighting.

Inspection

Comment on position, size, shape, surface, pulsations.

overlying skin and movement on deglutition and protrusion of the tongue.

Neck Measurements

Measure the circumference of the neck at the most prominent part of the swelling.

Palpation

• Patient's neck is slightly flexed (to relax muscles).
• Examine from the front or from behind the patient.
• Otto's method: Place the thumb and fingers on the thyroid. Palpate the thyroid when the patient swallows.
• Lahey's method -Push the thyroid to one side Palpate the lobe on the side which becomes prominent.

Comment on position, size. shape, surface, consistency (uniform, variable, cystic, solid, firm. hard), mobility (Hortzontal and vertical), tenderness and on the рутаmidal lobe If present

Auscultation

For thyroid bruit

Others

1. Carotid pulse. Present or absent on each side.

2. Horner's syndrome.

3. Kocher's test: Press the lateral lobes of the thyroid (stridor occurs In compressed trachea).

4. Lymph nodes for secondaries.

 General Examination

1. Relevant examination to elicit-symptoms and signs of hyper or hypothyroidism.

2. Eye signs.

Additional examination

a. Tongue: For any lingual thyroid.

b. Pemberton's sign: flic patient raises both his/her arms until they touch the ears. Hold up for some

time. Congestion of the face, cyanosis and distress occur In a retrosternal goitre.

How to elicit the eye signs of thyroid disease an OSCE guide

Following are the important eye sign in thyroid disease.

1.Exophthalmos: Unilateral or bilateral.

Comment on the widened palpebral fissure, visibility of the sclera above and below the limbus.

2. Von Graefe's sign:

3. Stellwag's sign Observe for retraction of upper eyelid and Infrequent blinking.

4.Joffroy's sign

5.Moebles sign: Look for Inability to converge the eyes.

How to elicit Pemberton's sign:an OSCE guide

Pempertons sign is seen in retrosternal goitre

• The  patient raises both his/her arms until they touch the ears. 
• Hold up for sometime. 
• Look for congestion of the face, cyanosis and distress in a retrosternal goitre.

This sign demonstrate the presence of latent pressure in the thoracic inlet

Pemberton's sign was named after Dr. Hugh Pemberton

A positive Pemberton's sign is seen in  superior vena cava syndrome (SVC), as  a result of a mass in the mediastinum. the sign is most commonly described in patients with substernal goiters where the goiter “corks off” the thoracic inlet.this maneuver is very  useful in any patient with adenopathy, tumor, or fibrosis involving the mediastinum

How to elicit Joffroy's sign an OSCE guide

In Joffroy's sign there is a lack of wrinkling of the forehead when a patient looks up with the head bent forwards

Joffroys sign is a sign of hyperthyroidism.It is elicited as follows

• Patient's face is inclined downwards.
• Patient attempts to look up.
• Look  for absence of wrinkles on the forehead.

How to elicit Von Graefe's sign:an OSCE guide

Von Graefes sign is an important eye sign in hyperthyroidism.It is elicited as follows

• The patient looks straight ahead.
• Ask the patient to look down.
• Look for a lag of the upper eyelid.

It is the lagging of the upper eyelid on downward rotation of the eye and indicate  underlying  Graves' Disease

The terms lid lag and von Graefe's sign have been used interchangeably in the past; but, they are distinct signs of downgaze-related upper eyelid static position and dynamic movement, respectively.

What is cretinism ?

Cretinism is a condition produced due to hypothyroidism since birth due to partial or complete failure of thyroid gland  (commonly it is due to thyroidal agensis).

Juvenile myxoedema is a condition with onset of hypothyroidism since childhood but develops before puberty ,this is only due to dyshormonogenesis

Myxoedema is characteried by onset of hypothyroidism after puberty (probably Hashimolo's thyroiditis is the commonest cause of myxoedema).

What are the morphologic characteristics of cretin?

 The facies in cretinism 

• Appearance is dull and idiotic.
• There is depressed bridge of the nose, broad flat nose with big nostrils.
• Hypertelorism (widely set eyes) with wrinkling of eyebrows : narrow palpebral fissures.
• Cretin has Sparse hair with dry skin.
• Their lips are thick and everted with big, protruded tongue (macroglossia)
• There is Delayed dentition.

The other features are

• Short stature but they maintains the infantile proportion, ie. upper segment > lower segment.
• These patients are lethargic and apathetic.
• Memory is grossly impaired. Markedly retarded intelligence
• Skin is dry. rough  and cold with sparse scalp hair.
• Thick and short neck with presence of supraclavicular pad ot fat.
• Pot-bellied abdomen with umbilical hernia is observed

Clinical features of hypothyroidism in neonatal period

Hypothyroididm in the neonatal period may be associated with the following

• Prolonged physiological jaundice.
• Somnolence.
• Feeding problem (difficulty in sucking)
• Constipation
• Hoarse cry 
• Delayed milestones of development (is observed in  later months)

How will you diagnose cretinism based on laboratory tests?

Blood investigations

• High serum cholesterol.
• Low protein bound iodine
• Low radioactive I131 uptake.
• T3 and T4 levels are low with high TSH level.

ECG - Low voltage complex is seen.

Skeletal x-ray (of long bones and pelvis) 

In cretinism there is delayed closure of epiphysis (i.e. bone age is less than that of chronological age).

Epiphyseal dysgenesis - Instead of one epiphysis, there are multiple epiphysis (This is DIAGNOSTIC of cretinism).

How will you treat Cretin?

• Very small dosage of L-thyroxine is needed. Initial dose is 10 to 25 microgram and the dose is adjusted according to clinical improvement as well as the biochemical findings.
• Rehabilitation.

Atypical manifestations of hypothyroidism

Thyroid hormone can directly influence every cell in the human body.Diagnostic confusion may occur when the functional derangement of one body system dominates the clinical picture.
Following are the common manifestations of hypothyroidism
Weight gain
fatigue
Cold intolerance
Puffy face
Constipation
Pedal edema
Atypical manifestation of hypothyroidism are not so rare.So high index of suspicion is necessary to diagnose the situation, this is very important because the disease is completely reversible and the treatment is cheap.When there is unexplained clinical conditions such as neuropsyhiatric, non responding cardiac,locomotor, gastrointestinal problems and in PUO(pyrexia of unknown origin) rule out thyroid dysfunction (can be hypothyroidism or hyperthyroidism)  including auto immune status.
Psychiatric manifestations of hypothyroidism
Psychiatric symptoms are common in both overt hypothyroidism as well as in subclinical hypothyroidism.Depression may be the first or sometimes the only clinical manifestation in hypothyroidism.Hypothyroidism may manifest as a variety of other neuropsychiatric symptoms which include
Mood disorders
Psychosis
Mania
Bipolar disease
Delusions
Visual and auditory hallucinations
Cognitive dysfunction
Impaired concentration
Decline in intelligence
Memory disturbance
Dementia
Cognitive dysfunction are more pronounced in elderly, hence it should be considered as a reversible cause of dementia.
Dermatological manifestations of hypothyroidism 
Sometimes dermatological manifestations are initial manifestation of hypothyroidism.
This may present as pruritus or urticaria .Symptoms may continue even after correction of hypothyroidism.
Muskuloskeletal manifestations of hypothyroidism
Arthralgia, arthritis
If there Is predominant small joint involvement of hands it mimick rheumatoid arthritis
Hypothyroidism can  also involve large joints producing myxedematous arthropathy is characterized by synovial thickening, ligamentous laxity and  effusion
Hyperuricemia may contribute to joint pathology.
Joint involvement is more common when the hypothyroidism is of autoimmune etiology
Other presentations are 
Infertility
Menorrhagia
Association with other endocrine dysfunction.
Hyponatremia  is seen in 10 % of hypothyroid patients.Mechanism of hyponatremia in hypothyroidism are due to
Reduction in GFR, impairement of water excretion
Inappropriate release of ADH
When there is unexplained reduction in serum sodium, always evaluate thyroid function
Hyperprolactinemia,headache may be a rare manifestation of hypothyroidism.It may be due to increased TRH production,thyrotrope  hyperplasia  and pituitary  enlargement.Normalization of symptoms occur with thyroid replacement.