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!