Thyroid Assessment - Medical Deep Dive

[Music] okay so let's have another look at this so my name's James Gill and this is another podcast for the rubber glove series of medical revision podcasts brought to you in association with titanium health or your local needs okay that's done so today we're going to talk about the thyroid examination this is a very common examinations is done very early aren't most medical schools and we're going to try and look at some of the science behind what it is that you do so I think we need to really start off and look that the patient globally you know what effect do patients with hyper or hypo thyroidism have and then we'll go on to look at why we do different bits on the examination and also just probably chat around things that can affect the thyroid in different ways across the episode so what is the thyroid gland the thyroid gland is an endocrine or hormone gland found at the very bottom of the neck here just beneath your thyroid cartilage and it's there really to act as the accelerator for the body if we're going to use an analogy from cars if you've got a hypo or low functioning thyroid then it's like you can't press down very hard on the accelerator everything's slow a little bit sluggish and difficult to get going conversely if everything if you've got a hyperthyroidism or an overactive thyroid then it's like your accelerators slammed flat to the floor and you're driving around in second gear all the while you've got awful lot of acceleration but everything's just cracked up to 11 and you're running you're going to run the engine down you know to potentially cause damage over the long term and we see that with a patient where they may have risks to their heart remodeling in the long term if we if they have an untreated hyperthyroidism so let's start off by just doing a brief overview of the broad symptoms that we may find in hyper and hypo thyroidism and that will give us an idea of the things that we're going to look for in the examination it's not unusual to find out that a patient has a problem with their thyroid based upon the symptoms that they come into the clinic with and we need to highlight again that symptoms other things patients come in with other things that they complain about the problems that they have versus signs which are the things that doctors look for and may observe on a patient so in terms of the symptoms a patient who has hypo or underactive thyroid may come in and say that they are feeling very tired that they're having problems putting on weight and that they're very cold if we compare that to somebody who's hyperthyroidism that patient may be losing weight and for no obvious reason they may find that they're very agitated a lot at the time and a little bit skittish if you will you know they can't sit still very well and in addition to that whereas our hypothyroidism patient under active patient is feeling cold our hyperthyroidism patient it's going to feel very hot all the while they're going to want the heating turndown you know they'll be running around in winter and just shorts and t-shirts when everyone else is bundled up in their heavy coats and jumpers so you can begin right from the get-go to get an image of what these patients might look like in your head a patient that has hypothyroidism or an underactive thyroid may come in with problems with their hair they made comment that the hair is dry or that they're getting hair coming out or that they're losing hair on the body generally our hyperthyroidism patient they may still have hair loss as well but it tends to be more generalized it's a thinning of the hair they might also comment though that the hair is brittle it's snapping very easily if we check some of the patient signs that they've come in with if we have a look at their pulse we may see it in a hyperthyroidism patient the pulse is much faster than normal a tachycardia and it now hypothyroidism patient we may find it bradycardia that things are a bit slower we'll talk a little bit more about those in a moment or two in detail the hands are an excellent place to look at as we're going to show in many of the videos with our hypothyroidism patient we can get problems with brittle nails we can get dry scaly skin and the hands can actually be a little bit swollen there can be slightly puffy by comparison a patient that has hyperthyroidism they may come in with issues with clubbing so those swellings to the destroy balances on or on the fingertips which we'd see by putting patients fingers together and seeing if we've got that diamond between or shamrock sign so hyperthyroidism is one of that list of things for our clubbing that we need to keep in mind other course of clubbing can be split from their systems so we can have cardiovascular causes abdominal causes respiratory causes and General Quarters I would sent to put hyperthyroidism in general along with say for example non-hodgkins lymphoma what are the other causes of clubbing that you can remember if we think about cardiovascular we may have problems with cyanotic heart disease so something like tetralogy of Fallot that wonderful one from medical school but it's here sub acute a bacterial endocarditis we've got an infection in the heart on the respiratory side of things we may find that we have a patient that has a bronchiectasis so widening of the Airways and a lot of mucous production they might have an emphysema so where they've got a dilation of the actual alveoli and destruction down there if they have a problems with asbestosis and pleural thickening if they've got additional issues with the lungs overall something like an abscess that's taking up some space there in the lung and making them feel generally sick abdominal side we've got liver cirrhosis and we've got actually the abdomen itself was problems with inflammatory bowel disorders there are lots of course for clubbing and it's important that you have a list in your head at least five things that you can reel off without too big a difficulty other things that the patient might come and talk may relate to that well throat themselves they make comment of a swelling there which may be causing difficulty swallowing or potentially changes in their voice thinking about the things that a patient can come in with as problems that they're presenting to something on the female side hypothyroidism patients might have problems with their periods so they may find that they're getting very heavy periods that the bleed happens for a longer period of time and they may experience an infertility as a result of this in addition they may find that the periods are becoming further apart so rather than a regular 28-day cycle we can end up having months and months between the periods so it's always worthwhile if a patient says that that we do think about hypothyroidism are under active thyroid but we also keep in mind could this be pregnancy on our hyperthyroidism side when they find that the bleeding gets shorter and much lighter some patients with hypothyroidism might stop bleeding a period altogether in addition like a hypothyroidism patient they may have problems with the fertility another thing that could happen with our hypothyroidism patient the period between the menstruation gets larger with our hyper or overactive it may become irregular as well as shortened so you may have a period one week then nothing for the next two weeks then you may have three weeks after a period and several bleeds across the month it can vary variable so that's our broad overview on the thyroid let's look over some specific bit shall we an important bit of terminology that's worthwhile discussing at this point is hyperthyroidism an overactive thyroid versus thyrotoxicosis high levels of thyroxine in the blood now a patient may have hyperthyroidism that their thyroid is working overtime putting excess thyroxine in the blood so your hyperthyroidism patient can also have thyrotoxicosis however I can take a hypothyroidism patient so they have low levels of thyroid seen in the blood and give them excess levothyroxine and medication to replace the thyroxine give them too much and cause them to go into thorough toxicosis they have to higher levels of thyroxine in the blood but that patient does not have hyperthyroidism hopefully you can see the distinction there between the two there are two types of autoimmune thyroid disease with the eponymous names Graves disease and Hashimoto's thyroiditis I was had difficulty remembering these because they're they're similar types of problems the immune system is affecting the thyroid in some way with Graves disease you have antibodies to the thyroid stimulating hormone the TSH receptor on the thyroid so these antibodies are produced by the body drive the thyroid harder causing thing hyperthyroidism patient I've always remembered that that hyperthyroidism is much more severe and can result in death ie might end up with you going in your grave by comparison Hashimoto's thyroiditis is still to do with autoimmune antibodies but this time they're coming to destroy the thyroid gland resulting in a hypothyroidism patient which we can easily treat with repeat replacing their thyroxine levels so that's a reasonable overview of the thyroid in terms of what may or may not come in the door but it's important that we make sure the information we get from the patient is also has sufficient clarify a Shinto it so on each of these symptoms I want to know what the onset is what the duration is how bad the or the severity of these symptoms whether or not they're intermittent or continuous what's the course of this have they noticed that there may be any precipitating factors for example have they started any new medications we'll see in a minute that there are medications that can cause fire roid disease in terms of hypothyroidism but also cause the thyroid to be overactive and are there any family members that have had similar problems to this in the past always really useful to find out so what drugs can cause hypothyroidism under active thyroid the first one amiodarone is a cardiac drug well we used to treat arrhythmias a bit of a dirty medication if of course fibrosis in a patient so before we start that we must do a chest x-ray and check their thyroid gland to make sure there are no problems there lithium if we've got a patient who has bipolar that can cause hypothyroid of patients hence why this is a medication we must ensure that we monitor the patients with carefully phenytoin one of our antiepileptic medications can cause an increase in thyroid hormone consumption so whilst it's not affecting the thyroid gland itself the hormone that the thyroid is producing is broken down faster when you're using this medication if we have carbamazepine another anti epileptic medication that can stop the thyroxine the t4 being released into the blood so there are medications acting directly on the thyroid so to valper eight another anti epilepsy medication are you noticing about in here can cause hypothyroidism but only sub clinically so by chemically when we have a look at their blood results we can see evidence of hypothyroidism but we don't actually have the patient normally complaining of symptoms another medication you may be aware of diazepam can cause hypothyroidism we also need to think about the progesterone only pill because this can affect thyroid stimulating hormone uptake so it may mean the gland isn't responsive as it should be two signals to say make more highroad hormone making it hypothyroidism patient and finally the most important medication that causes hypothyroidism is carbon as all I say that because this is a medication we use to intentionally branch it down the thyroid gland when we have a patient that has hyperthyroidism so obviously we want to make sure that we're not giving a patient that accidentally now if we look at drugs that can cause hyperthyroidism the first medication on our list surprisingly is amiodarone yes this can cause both a hypothyroidism as we've seen but in six percent of people can actually push the Theroux to become overactive giving a hyperthyroidism Crucified can a theoretically cause a hyperthyroidism but that's more academic in the sense that because it's a diuretic or a water tablet helping patients to lose fluid it can cause the blood to be more concentrated and thus you've got more thyroxine than you had before by comparison just it's more concentrated in the blood now we talked about the progesterone only pill having issues with hypothyroidism but estrogen and HRT can potentially cause hyperthyroidism but this is a very very rare side effect finally something to think about is iodine containing medications because iodine is used to stimulate the thyroid gland so in places such as Derbyshire for example classically you get hypothyroidism and a big Gator called Derbyshire neck that was because Derbyshire being so far inland is actually the furthest point from the sea and this has the least amount of iodine in the I'm from Derbyshire myself but so far I'm unaffected by this although some people might consider myself to be slightly slow on the uptake some days in terms of iodine no iodine is actually seen some cough medications so we can find that if a patient's taking too much iodine in from various sources then that can push a patient to have an overactive thyroid from a neurological standpoint in the same way that our hypothyroidism patient is a bit lethargic they're feeling slow they might have difficulty concentrating or paying attention to things if we check their reflexes we're going to find that actually unlike normal they're going to have slow reflexes by comparison our hyperthyroidism patient they're likely to have brisk reflexes that respond much faster than we might expect things to happen so that completes this thyroid overview for the rubber glove podcast I hope this has been useful for you I've tried to look over some of the background science but also that mainly focused on the reasons why we do and look for particular things in the clinical examination hopefully giving you a more of a grounding as to what it is you're doing every time you examine these patients please feel free to give as much criticism as you'd like and the feedback down below I can't get any better with these if I don't know how you would like me to improve or how I could change things so please stick hit the like button and the follow and I'll see you for the next one take care