Post on 13-May-2017
transcript
Batul Kaj & Samreen Rizvi4th year medics
Outline of SessionNeck and thyroid examEndocrine historiesInterpreting ECGs
Greet, introduce yourself, gain consentExpose and seat patient appropriately, ask
about painINSPECT
Paraphenalia, scars, lumps, skin changes, neck veins
Mouth – tonsillitis, uvular deviation, thyroglossal cyst, gag reflex
Swallowing – pain/discomfort, thyroidPALPATE
From front – trachea, carotids, JVPFrom behind – anterior and posterior triangles,
thyroid and LYMPH NODES
PERCUSSSternum – retrosternal goitre
AUSCULTATEBruits – carotids and thyroid
Thank patient, say they can get dressedTo conclude:
Thyroid exam if you’ve found a thyroid!Test movements of neck
What are the margins of the neck triangles?What are the lymph node groups?Which node is most important to check for in
neck/thyroid exam and why?
A few questions...
Greet, introduce yourself, gain consentExpose and seat patient appropriately, ask about
painINSPECT
Appearance – agitated? Appropriate clothing?Hands – temperature, tremor, palmar erythema,
thyroid acropachy, clubbingPulse – rate and rhythm and mention BPFace – eyebrows, features, skinEyes – chemosis, anaemia, exopthalmos, lidlag,
opthalmoplegiaMouth – tonsillitis, thyroglossal cystSwallowing – pain/discomfort, thyroidNeck – scars, swellings, skin changes, distended
veins
PALPATEFrom behind
Thyroid. If you find a goitre, characterise by: Size Shape Site Single or multiple swellings? Consistency – soft, firm? Uniform, varied? Surface – smooth or nodular? Tenderness Location – retrosternal? Check on swallowing
Lymph nodes – esp. jugulodigastric at jaw angleFrom front – trachea, carotids
PERCUSSSternum – retrosternal goitre
AUSCULTATEBruits – carotids and thyroid
If you have time/to conclude:ReflexesProximal myopathyPretibial myxoedema
Thank patient, say they can get dressed
Common endocrine symptoms
Changes in:Appetite and weight Bowel habits SweatingHair distribution Skin texture and pigmentationMenstrual cycleMicturition
Lethargy/agitationStatureImpotenceNeck lumps
History 1You are a medical student at an endocrine
outpatients clinic. The next patient is a 25-yr-old man, who has been referred by his GP with a worsening frontal headache. Please take a history of the presenting complaint with a view to making a diagnosis.
History 2The next patient is a 54-yr-old woman, who has
been referred to outpatients with a croaky voice and weight gain. Please take a history of the presenting complaint with a view to making a diagnosis.
History 3You are a medical student at a GP surgery. The
next patient is a 34-yr-old woman, who has come in to get sleeping tablets and says she also “can’t get out of bed in the morning”. Please take a history of the presenting complaint with a view to making a diagnosis.
Common endocrine syndromes
ThyrotoxicosisHeat intolerance, weight loss, increased appetite, palpitations,
increased sweating, nervousness, irritability, diarrhoea, amenorrhea, muscle weakness, exertional dyspnoea
HypothyroidismCold intolerance, lethargy, eyelid swelling, hoarse voice,
constipation, coarse skin, hypercarotenaemia
Diabetes MellitusPolyuria, polydipsia, thirst, blurred vision, weakness,
infections, weight loss, fatigue, lethargy
Common endocrine syndromes
AcromegalyFatigue, weakness, increased sweating, weight gain, enlarging
hands and feet, enlarged and coarsened facial features, headaches, visual impairment, impotence
AddisonsFatigue, weakness, weight loss, increased skin pigmentation
(at skin creases esp), faintness, low BP, N & V, salt cravings
CushingsCentripetal weight gain, moon face, excess hair growth, high
BP, sleep disturbance, easy bruising, thin skin, poor healing, striae, mood changes, proximal myopathy, impotence
http://books.google.co.uk/books?id=nyElXWQSFucC&pg=PA307&lpg=PA307&dq=taking+an+endocrine+history&source=web&ots=UP94CT0UTC&sig=i0RvYKHbCME_KKLEWI6Arpx-_-k&hl=en#PPA323,M1
First result when you Google search “taking an endocrine history”
Samreen Rizvi
Electrical conduction in the heart
Electrode positions
Basic details
Reporting an ECGIntro, pt name, DOB, symptomsAdequate calibration & paper speedHeart rate and rhythm, regular/irregularCardiac axisIntervals:
P waveQRS complexST segmentT waveQT intervalBundle branch block
Normal 12-lead ECG
Paper speed 25mm/s
1mV
Your turn...
Atrial fibrillationMr J Smith,13.12.1952, 10.3.2008, 1pmNo symptoms
Paper speed 25mm/s
1mV
Atrial flutter
Sawtooth waves
Mrs A White,10.11.1960, 01.04.2008, 3pmPalpitations
Paper speed 25mm/s
1mV
Anterior MIMr J Bloggs, 5.08.1967,15.04.2008, 3pmChest pain, SOB
Inferior MI
ST elevation in the inferior leads II, III and aVF Reciprocal ST depression in the anterior leads
Mr A Brown, 01.01.1959,15.04.2008, 3pmChest pain, SOB
LVHMr B Green, 15.02.1969,15.04.2008, 4pmPalpitations, chest pain
Paper speed 25mm/s
1mV
SummaryLBBBMr A GreyChest pain
Paper speed 25mm/s
1mV
‘RSR’ in lead V1
VTMr B Jones, 5.08.1967,15.04.2008, 3pmPalpitations
Paper speed 25mm/s
1mV
Heart blockFirst degree AV block
Prolonged PR interval
Heart blockSecond degree AV Block Type 1
(Mobitz)Mobitz I or Wenckebach.
Progressively lengthening PR with a dropped P wave
Heart blockType II Second degree AV Block
Constant PR interval with dropped P waves
Third Degree Complete Heart Block
No relationship between P and QRS complexes
My turn…
“This is a 12 lead ECG of Mr Jones, date of birth, 1st January 1956,. This ECG was taken on 12th March 2008 and there was no chest pain or other symptoms at the time of the ECG. The sensitivity of the ECG shows that 1mV is represented by 10mm and the paper speed is 25mm/s which is appropriate. To comment on the Rate, (300/4bsq) is 75 beats per minute and is regular. I am looking for P waves before each QRS complex which there is so I can say that this patient is in sinus rhythm. Looking at the axis, lead I appears to have an overall positive deflection as does aVF so I can conclude that this is a normal axis with no axis deviation. For the intervals, the P wave is less than 5 small squares and the QRS complex is less than 3 small squares which are both normal. The ST segments appear to be normal, there is no obvious ST elevation or depression I can see. The T waves appear to be normal. There does not appear to be any evidence of bundle branch block in the chest leads.
In summary, this is a normal ECG of Mr Jones.”
Next week...GALS Examination!Urological HistoriesExplanation to a newly diagnosed patient
Session 8 @ 3pm in GlenisterContact: bk04; sr804See website: union.ic.ac.uk/medic/muslim for all
slides, handouts and timetablesBecome a MM member if you want priority in the
mock OSCE!