{"id":1037,"date":"2018-01-30T11:31:51","date_gmt":"2018-01-30T11:31:51","guid":{"rendered":"http:\/\/drcrunch.co.uk\/blog\/?p=1037"},"modified":"2018-01-30T11:31:51","modified_gmt":"2018-01-30T11:31:51","slug":"go-to-the-goitre","status":"publish","type":"post","link":"http:\/\/drcrunch.co.uk\/blog\/2018\/01\/30\/go-to-the-goitre\/","title":{"rendered":"Go to the goitre"},"content":{"rendered":"<p>&nbsp;<\/p>\n<figure id=\"attachment_1038\" aria-describedby=\"caption-attachment-1038\" style=\"width: 175px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" data-attachment-id=\"1038\" data-permalink=\"http:\/\/drcrunch.co.uk\/blog\/2018\/01\/30\/go-to-the-goitre\/thyroidhyper\/\" data-orig-file=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?fit=999%2C1717\" data-orig-size=\"999,1717\" data-comments-opened=\"1\" data-image-meta=\"{&quot;aperture&quot;:&quot;0&quot;,&quot;credit&quot;:&quot;&quot;,&quot;camera&quot;:&quot;&quot;,&quot;caption&quot;:&quot;&quot;,&quot;created_timestamp&quot;:&quot;0&quot;,&quot;copyright&quot;:&quot;&quot;,&quot;focal_length&quot;:&quot;0&quot;,&quot;iso&quot;:&quot;0&quot;,&quot;shutter_speed&quot;:&quot;0&quot;,&quot;title&quot;:&quot;&quot;,&quot;orientation&quot;:&quot;0&quot;}\" data-image-title=\"thyroidhyper\" data-image-description=\"\" data-medium-file=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?fit=175%2C300\" data-large-file=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?fit=700%2C1203\" class=\"wp-image-1038 size-medium\" src=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?resize=175%2C300\" alt=\"Hyperthyroidism cartoon\" width=\"175\" height=\"300\" srcset=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?resize=175%2C300 175w, https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?resize=768%2C1320 768w, https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?resize=700%2C1203 700w, https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/thyroidhyper.png?w=999 999w\" sizes=\"auto, (max-width: 175px) 100vw, 175px\" data-recalc-dims=\"1\" \/><figcaption id=\"caption-attachment-1038\" class=\"wp-caption-text\">If only patients presented with handy thought bubbles&#8230; Illustration by Surabhi Khanna<\/figcaption><\/figure>\n<p>Giselle Oyter is a 49 year old woman who complains of sweaty palms, hot flushes and anxiety for the past 2 months. Her periods have been a bit irregular for the past 4 months. She is convinced she is going through the changes and has taken <a href=\"http:\/\/www.cochrane.org\/CD007244\/MENSTR_black-cohosh-cimicifuga-spp.-for-menopausal-symptoms\" target=\"_blank\" rel=\"noopener\">black cohosh<\/a>.<\/p>\n<p>You put on your 1950s detective jacket, smoke your e-pipe and ponder if the real problem is the thyroid.<\/p>\n<p>You stare at her neck, and her neck stares back at you without telling you where its thyroid gland is. You&#8217;ll have to find it yourself&#8230;<\/p>\n<p><span class=\"embed-youtube\" style=\"text-align:center; display: block;\"><iframe class='youtube-player' type='text\/html' width='700' height='394' src='https:\/\/www.youtube.com\/embed\/lmEus_ZDipg?version=3&#038;rel=1&#038;fs=1&#038;autohide=2&#038;showsearch=0&#038;showinfo=1&#038;iv_load_policy=1&#038;wmode=transparent' allowfullscreen='true' style='border:0;'><\/iframe><\/span><\/p>\n<p>In other words, feel down the neck looking for the following landmarks:<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" data-attachment-id=\"1039\" data-permalink=\"http:\/\/drcrunch.co.uk\/blog\/2018\/01\/30\/go-to-the-goitre\/feeling-down-the-neck-01\/\" data-orig-file=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?fit=1453%2C2235\" data-orig-size=\"1453,2235\" data-comments-opened=\"1\" data-image-meta=\"{&quot;aperture&quot;:&quot;0&quot;,&quot;credit&quot;:&quot;&quot;,&quot;camera&quot;:&quot;&quot;,&quot;caption&quot;:&quot;&quot;,&quot;created_timestamp&quot;:&quot;0&quot;,&quot;copyright&quot;:&quot;&quot;,&quot;focal_length&quot;:&quot;0&quot;,&quot;iso&quot;:&quot;0&quot;,&quot;shutter_speed&quot;:&quot;0&quot;,&quot;title&quot;:&quot;&quot;,&quot;orientation&quot;:&quot;0&quot;}\" data-image-title=\"feeling down the neck-01\" data-image-description=\"\" data-medium-file=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?fit=195%2C300\" data-large-file=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?fit=700%2C1077\" class=\"aligncenter wp-image-1039 size-large\" src=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?resize=700%2C1077\" alt=\"\" width=\"700\" height=\"1077\" srcset=\"https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?resize=700%2C1077 700w, https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?resize=195%2C300 195w, https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?resize=768%2C1181 768w, https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?w=1453 1453w, https:\/\/i0.wp.com\/drcrunch.co.uk\/blog\/wp-content\/uploads\/2018\/01\/feeling-down-the-neck-01.png?w=1400 1400w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" data-recalc-dims=\"1\" \/><\/p>\n<p><strong>What are the goals of the thyroid examination?\u00a0<\/strong><\/p>\n<ol>\n<li>What is the patient&#8217;s thyroid status?<\/li>\n<li>Is there a thyroid lump, and if so, what is it?<\/li>\n<li>Is there evidence of Grave&#8217;s disease specifically?<\/li>\n<\/ol>\n<p><a href=\"http:\/\/www.drcrunch.co.uk\/students\/downloads\/ThyroidOSCE.doc\" target=\"_blank\" rel=\"noopener\">I&#8217;ve summarised the examination on this handout, <\/a>as well as explained the rationale behind each step. This video is the shortest summary I found:<\/p>\n<p><span class=\"embed-youtube\" style=\"text-align:center; display: block;\"><iframe class='youtube-player' type='text\/html' width='700' height='394' src='https:\/\/www.youtube.com\/embed\/YjARTs0DsjU?version=3&#038;rel=1&#038;fs=1&#038;autohide=2&#038;showsearch=0&#038;showinfo=1&#038;iv_load_policy=1&#038;wmode=transparent' allowfullscreen='true' style='border:0;'><\/iframe><\/span><\/p>\n<p><strong>What is a goitre?<\/strong><\/p>\n<p>A fancy was of saying an enlarged thyroid gland. It is generally <em>diffuse<\/em>, whereas nodules are <em>focal<\/em>.<\/p>\n<p><strong>What did that patient have then?<\/strong><\/p>\n<p>A large, diffuse goitre combined with a hyperthyroid state. \u00a0This is most likely to be Grave&#8217;s disease. It&#8217;s not uncommon for this to be masquerading as the menopause. Other signs you might expect (generally in advanced disease) include thyroid acropatchy (which looks exactly like clubbing, and may extend a bit more proximally to include swelling of the digits), Grave&#8217;s ophthalmoplegia and pretibial myxodema.<\/p>\n<p><strong>Which\u00a0is Grave&#8217;s\u00a0ophthalmoplegia called a complex\u00a0ophthalmoplegia?\u00a0All opthalmoplegias seem complex to me&#8230;<\/strong><\/p>\n<p>Ophthalmoplegia refers to any weakness of the eye muscles. Any opthalmoplegia which cannot be attributed to any one cranial nerve is called a complex ophthalmoplegia. In Grave&#8217;s, there is impairment of specific extra ocular muscles as opposed to a cranial nerve. This is similar to myasthenia gravis.<\/p>\n<p><strong>Palpation of any lump<\/strong><\/p>\n<p>This is simple \ud83d\ude42<\/p>\n<ul>\n<li>Inspection<\/li>\n<li>Palpation<\/li>\n<li>Special tests<\/li>\n<li>Lymph nodes<\/li>\n<\/ul>\n<p>The main way you can go wrong is if you forget lymph nodes. Lymph nodes are everything. If there is a regional lymph node, suspect a cancer. For example, NICE guidelines for breast cancer referral state to consider referring <em>even in the absence of any breast lump<\/em> if:<\/p>\n<blockquote><p>Aged 30 and over with an unexplained lump in the axilla<\/p><\/blockquote>\n<p>That&#8217;s how intense unexplained lymph nodes are.<\/p>\n<p><strong>Mnemonics<\/strong><\/p>\n<ul>\n<li>Size<\/li>\n<li>Shape<\/li>\n<li>Surface<\/li>\n<li>Surface changes<\/li>\n<li>Consistency<\/li>\n<li>Contours<\/li>\n<li>Colour<\/li>\n<li>Compressibility<\/li>\n<li>Temperature<\/li>\n<li>Tenderness<\/li>\n<li>Transillumination<\/li>\n<li>Tethered<\/li>\n<\/ul>\n<p>Special tests:<\/p>\n<ul>\n<li>Reducibility<\/li>\n<li>Pulsatility<\/li>\n<\/ul>\n<p>Then don&#8217;t forget regional LYMPH NODES.<\/p>\n<p><strong>AND THEN PALPATE THE LYMPH NODES AGAIN AND AGAIN AND AGAIN.\u00a0<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; Giselle Oyter is a 49 year old woman who complains of sweaty palms, hot flushes and anxiety for the past 2 months. Her periods have been a bit irregular&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"spay_email":"","footnotes":"","jetpack_publicize_message":""},"categories":[1],"tags":[],"class_list":["post-1037","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"jetpack_featured_media_url":"","jetpack_publicize_connections":[],"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p9zRNY-gJ","jetpack_likes_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/posts\/1037","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/comments?post=1037"}],"version-history":[{"count":1,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/posts\/1037\/revisions"}],"predecessor-version":[{"id":1040,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/posts\/1037\/revisions\/1040"}],"wp:attachment":[{"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/media?parent=1037"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/categories?post=1037"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/drcrunch.co.uk\/blog\/wp-json\/wp\/v2\/tags?post=1037"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}