Surgery

UROLOGY
1.
2.
3.
4.

Urinary Retention
Flank pain/Renal Colic
Impotence
Hematuria

Take hx from man with acute urinary retention

PEP: most likely dx, ddx, investigations
60s man presents with acute urinary retention. History only.
PEP:
(1) Physical examination shows an enlarged prostate. What is the next step in management?
50s man presents with acute flank pain. Physical exam only. Physical exam shows CVAT.
PEP: Interpret IVP (shows unilateral hydroureter and stone at PU jxn)
Renal Colic / Pyelo
Surg
35 year old male presents with colicky left sided abdo pain. Do a focused physical exam.
Findings: no peritoneal findings, no organomegaly, tenderness over the left CVA.
Questions: IVP provided, assess (shows filling defect). Patient returns two days later with worsening pain
and temp. What investigations would you order? The patient receives septra despite having an allergy to
sulpha documented on the chart. He breaks out into hives, receives benadryl, and is giving another
antibiotic instead. What are your responsibilities now (3)?
Take hx and counsel man with impotence (10 min station)
Renal colic
History
pain: OPQRST
previous history of pain
associated GU symptoms: dysuria, hematuria, frequency, urgency
GI symptoms: nausea, vomiting, bowel symptoms
gyne symptoms: discharge, sexual history
constitutional symptoms
past medical history
family history
medications, allergies
social: smoking, alcohol
PEP
type of stone (90% of stones radioopaque KUB)
calcium stones 80%: calcium oxalate and calcium phosphate
increase water intake, avoid oxalate foods (caffeine, potatoes, rhubarb)
correct underlying cause
struvite stones 10%: triple phosphate, staghorn calculi, due to infection by Proteus,
Klebsiella, Pseudomonas, Provididencia, Staph aureus
complete stone clearance
acidify urine
antibiotics for 6 weeks with follow up urine cultures

uric acid stones 10%: radiolucent on Xray

increase fluid intake, avoid high protein/purine diet
alkalinize urine
allopurinol
cystine stones
increase fluid intake, avoid high protein/purine diet
alkalinize urine
management
medical: if < 5mm = do nothing (one mo. of medical tx before considered failed)
surgery
kidney
ESWL if stone is < 2.5 cm
+ stent if stone is 1.5 - 2.5 cm
percutaneous nephrolithotomy if >2.5 cm, staghorn, UPJ obstruction,
cystine stone
open nephrolithotomy if extensively branched staghorn
ureter
ESWL
ureteroscopy: failed ESWL, ureteric stricture, distal 1/3 of ureter
IVP: find stone and describe findings
anatomy
obstruction
extravasation of dye
uric acid = filling defect

Hx for nephrolithiasis
HPI: symptoms c/w nephrolithiasis:
flank pain from renal capsular distension (noncolicky)
severe waxing and waning pain radiating from flank to groin due to stretching of collecting system or ureter
(ureteral colic)
never comfortable, always moving
nausea, vomiting
hematuria (usually microscopic), occasionally gross
frequency, urgency, diaphoresis, tachycardia, tachypnea (palipitations/SOB) (all of these are symptoms of
trigonal irritation)
ask about fevers/chills for pyelonephritis
make sure you have covered reasons why they may need to be admitted with stones: fever suggesting
pyelonephritis, solitary kidney, cant keep po meds down
ddx:
acute abdominal crisis (biliary, bowel)
leaking AAA
radiculitis (nerve root compression, herpes zoster)
pyelonephritis (fever, chills, pyuria)
-ask about risk factors for renal stones:
stasis: hydronephrosis (secondary to autonomic diabetic neuropathy, BPH, meds, etc), congenital
abnormality
infection (struvite stones)
increased oxalate, uric acid, hypercalciuria (ask about meds i.e. Probenecid, low dose NSAIDS, also
hyperthyroidism, gout, steroids)
PMHx:

medical illness important for causes of secondary hypercalcemia, or meds that may increase urate, calcium
or oxalate
surgical: congenital problem with GU system that was operated on as a child?
FHx: congenital problems (i.e. solitary kidney)
Gross hematuria
Hematuria - OPQRST, had it before?
color, timing and pattern of hematuria - initial (anterior urethral), terminal (bladder neck,prostate),
throughout (bladder or upper urinary tract)
Associated symptoms - flank pain, abdo pain, dysuria, urine output, frequency?
R/O coagulopathy - epistaxis, mucosal bleeding, melena, hemathrosis
Constitutional symptoms - fever, wt loss, chills, lethargy
ask re : ingestion of beets, dyes, menstruation, smoking,trauma
recent sore throat, strept skin infection (GN)
Past medical history - stones, foley cath, pyelo
Meds - cyclophosphamide, asa, coumadin, ibuprofen, allopurinol, phenobarb, naproxen
Family history - stones, bladder cancer, coagulopathy, renal disease, sickle cell, hypertension
PEP - Transitional Cell Carcinoma of Bladder - interpret IVP, initial investigations, Rx
Investigations - urinalysis, urine cytology, U/S, IVP
- staging - CXR, CT scan, liver tests
Rx - CIS --> TURBT + intravesical chemotx : BCG, thiotepa, mitomycin C
TIS,TaT1 --> TURBT and chemotx as above
invasive ds (T2-T3) --> radical cystectomy with urinary diversion + irradiation
metastatic ds (T4) --> irradiation and systemic chemotx
Hematuria history
ID/CC
HPI
Hematuria onset, amount of blood, timing (init=urethral, terminal= bladder neck, constant
bladder of above), colour, clots
Associated Symptoms
Pain (perineal/ abdo/ flank)
Irritative dysuria, urgency, freq, nocturia
Obstructive hesitancy, straining, intermittent stream, incomplete voiding, decreased
force/calibre of flow, post-void dribble
Provoking factors exercise, trauma
Previous kidney/urologic disease ( remember BPH, stones)
Recent UTI/STD/TB exposure/ pelvic irradiation/ bleeding diathesis
Recent URTI / sore throat (post-infectious GN)
Constitutional wt/fever/fatigue/ night sweats
Drugs NSAIDs/ anticoagulants / cyclophosphamide
Occupational dyes, leather, rubber, paint, benzene

ORTHO
1.
2.
3.

Shoulder pain
knee pain
ankle fracture

Construction worker with shoulder pain. Physical exam R shoulder. B. interpret xray, Ddx,Rx
Man with ankle sprain. Counsel re: rehab, care, f/u (10 min station)
Knee pain physical exam

Inspection compare with other knee, examine pt. Standing as well

Swelling, erythema, muscle atrophy, deformity (e.g. varus/valgus), skin changes
Gait
Palpation
Temperature
Joint line tenderness (knee at 90deg, also palpate collateral)
Effusion bulge sign (milk fluid up medial knee, pass hand down lateral side), ballotment
(balloon sign)
Patellofemoral compartment push patella against the femur and ask patient to flex quads pain
+/- crepitus
Bakers cyst
Neurovascular pulses, sensation, reflexes, motor
Movement
Passive and active look for decreased ROM on flexion, extension, and hyperextension
Special Manoeuvers
Medial/Lateral collateral Ligaments: valgus/varus stress to open up, feel for ligament
Anterior/ Posterior Cruciate Ligaments: sitting on patients foot with knee flexed 90 degrees, pull
leg towards/away from you
Menisci: McMurray test- knee flexed, leg externally rotated place valgus stress on knee then
straighten knee postive with palpable/audible click
Classically - pain along medial or lateral aspect of knee. Pain on full extension and pain along
joint line + effusion = meniscal tear.
Mention you would examine joints above and below knee as well

43 yo woman with right ankle injury - history and physical

History
details of accident: when, how did it happen (inversion, eversion, rotation)
associated symptoms: open wounds, ability to weight bear, pain in knee
any other injuries
previous ankle injury
past medical history
medications, allergies
smoking, alcohol
last meal
Physical
neurovascular status of ankle
pulses, capillary refill
sensory: L4 medial foot, L5 dorsum of foot 1st webspace, S1 lateral foot

 motor: L5 tibialis anterior (dorsiflexion), S1 gastroc/soleus (plantar flexion)

look for deformities, swelling, bruising
feel: pain in malleolar zone and tenderness distal 6 cm of medial or lateral malleolus
move: dorsi/plantar flexion, inversion/eversion, internal and external rotation
check for tenderness at knee (Maissoneuve fracture)
Remember:
ankle x-ray if 1) pain in malleolar zone and bony tenderness over distal 6 cm of medial or lateral
malleolus or 2) inability to weight both immediately and in ED
PEP - Ankle Fracture
discuss significance of Xray findings:
Ring principle of the ankle: lateral malleolus, medial malleolus, posterior medial malleolus,
deltoid ligament (medial), syndesmotic ligament (tib-fib), calcaneofibular ligament
AP, lateral and Mortise view (15 degrees internal rotation)
Mortise view: should be symmetric along joint line no > 4mm and no tilt
asymmetry means bony or ligamentous injury
discuss rehab and pain management one month later
undisplaced fractures: below knee cast
displaced fractures: reduction
ORIF: fracture-dislocations, type C fractures, trimalleolar fracture, talar shift/tilt

40 M presents with inability to weight bear on R hip. Has fevers, 1 day history of
painful hip. No steroids. No trauma. No IVDU. No dysuria, STD risk factors. Likely
septic hip. Hx and Px.
MEDICINE
PEP:

1.
2.

What is the diagnosis?

How do you manage this?

4. EXAMINE YOUNG MAN WITH ACUTE HIP PAIN see medicine

PEP: DDX, KEY HX POINTS, INVESTIGATION

GEN SX
1.
2.
3.
4.
5.
6.

abdo pain and vomiting - obstruction

epigastric pain - pancreatitis
rectal bleed
LLQ pain - diverticulitis
breast lump
RLQ - appendicitis

40s man presents with abdominal pain and vomiting. One BM before this started, now not passing gas.
Pain is colicky, in waves. No one ate with him at last meal. Prior appy. No IBD. Uncomfortable during
history. History only.
SURGERY
PEP:
1. Shows AXR with dilated SB loops and air-fluid levels. Interpret AXR
2. What is Dx (SBO)
3. How would you manage (NG, IV fluids)
4. If his pain worsens and his abdomen becomes peritoneal, and he becomes tachycardic what
would you do (3 things): (IV fluids, antibiotics, gen surgery consult)
40ish man w severe abdo pain x 24 hours. Relevant history. o/e: hx of appendectomy. No relevant hx
otherwise. Last BM 24 hours ago. WRITTEN: give three findings, + or -, on abdo films (he has dilated
SB, multiple air fluid levels, no free air). List three things in management. When, if ever, would you
consider consulting general surgery?
65 F with rectal CA does not want OR. Counsel her. Turns out her friend died with the same OR. Hx
only (counselling /CLEO)
SURGERY
Pancreatitis / Epigastric Pain
Surg
30 year old man presents with five hours of acute epigastric pain, with nausea and vomiting, getting worse.
Tachypneic, tachycardic, BP stable (given vitals at the door). Manage.
Findings: drinker, drank more the previous night watching the game, pain is epigastric and deep.
Question: his girlfriend calls asking for info, he insists that he doesnt want her to know anything, nurse
asks what should I do?.
Note: another question that came up at another site was this one, it is also probably a pilot station and may
not be used again:
A 40-year old patient is in your office for incision and drainage of a sebaceous cyst on his back. Perform
the procedure. In the room was a mock piece of skin with a sebaceous cyst in it. You had to perform the
procedure under sterile technique. You had to cut
deep enough so that fake pus came out of the wound, pack it with string-gauze and dress it appropriately.
Man with Rectal Bleeding
History
- blood in stools - frank blood vs on surface vs mixed with stools
- melena, hematochezia, hematemesis (coffee ground stools), tenesmus
- abdo pain - OPQRST ; Nx,Vx, abdo distention, diarrhea, constipation (change in bowel habits)
- any other sites of bleeding - mucosal bleed, hemarthosis, epistaxis, easy bruising etc
- sx of anemia - fatigue, dizziness, SOB, C/P etc
- constitutional sx - fever, chills, weight loss!!
- diet - ?fiber
meds - NSAIDS, ASA
past medical history - hx PUD, diverticulosis, coag disorders, vasculitides, hemrrhoids, alcohol
surgical hx - endoscopy, aortic surgery
fam hx - IBD, cancer, blood dyscrasias

PEP - signs of acute blood loss; on physical examination, focus on:

vitals - tachycardia, hypotension with postural changes, tachypnea, urine output??
H/N - dry mucous membranes, flat JVP
CVS - poor peripheral pulses and poor cap refill
Skin - cool, clammy skin, pale
CNS - decreased LOC, confusion
Hemorrhagic Shock :
Class
Blood loss
BP
Pulse
Resp rate
1
15%, <750
n
<100
14-20
2
15-30%, 750-1500
n
>100
20-30
3
30-40%, 1500-2000
dec
>120
30-40
4
>40%, >2000
dec
>140
>40

U/O per hr
>30
20-30
5-15
0

Examine LLQ pain in male diverticulitis

History
pain: OPQRS
previous similar pain
associated symptoms: nausea, vomiting, diarrhea, constipation, jaundice, weight changes
GU symptoms: dysuria, frequency, urgency, nocturia, hematuria
GI symptoms: N,V, dysphagia, loss of appetite, hematemesis, diarrhea, constipation, melena,
hematochezia
constitutional symptoms
past medical history
medications, allergies
social: smoking, alcohol
Physical
General Appearance
Vitals
Abdomen: look for signs of peritonitis, RECTAL

Woman with RLQ pain classic appendicitis

History
pain: OPQRS
previous similar pain
associated symptoms: nausea, vomiting, diarrhea, constipation, jaundice, weight changes
gyne symptoms (rule out ectopic and PID): LMP, sexual history, # of partners, vag discharge
GU symptoms: dysuria, frequency, urgency, nocturia, hematuria
constitutional symptoms
past medical history
medications, allergies
social: smoking, alcohol
Physical
General Appearance
Vitals
Abdomen: look for signs of peritonitis, RECTAL
Gyne: PELVIC exam
Investigations
CBC, lytes, BUN, Creatinine
beta HCG

pelvic US to rule out adnexal pathology

Breast lump - history

History
description of lump: size, location, mobility, tenderness, fluctuation with menstrual cycle
associated symptoms: skin changes/edema/erythema, nipple discharge/eczema/retraction
previous lumps: benign or malignant
constitutional symptoms
risk factors:
increasing age
family history: 1st degree relative
premalignant breast lesions
personal history of breast cancer
hormonal: age at first pregnancy, early menarche, late menopause, nulliparity
previous exposure to radiation
obesity, excess dietary fat, high alcohol consumption

past medical history

medications, allergies
social: smoking, alcohol

PEP
age groups: see previous chart with scenario on physical exam of breast lump
37 yo female wants a second opinion regarding breast examination (her sister has breast ca) physical exam
Physical
inspect
breast: 1) size & symmetry; 2) contour; 3) superficial appearance (peau dorange)
areola and nipple: 1) size & shape; 2) ulcerations/eczema; 3) discharge,
4)
supernumerary nipples
1) sitting with arms down; 2) arms raised; 3) hands pressed at hips; 4) lean forward
palpation
supraclavicular nodes
axillary nodes
breast
vertical strip method or radial vector method
boundaries: 2nd to 6th rib from sternum to midaxillary line
gentle, medium and firm pressure
medial breast: patient with arm behind head
lateral breast: oblique recumbent position (lie partly on other side to flatten out
lateral breast)
describe size, shape, consistency, delineation, tenderness, mobility
if time left over: chest exam, abdominal exam
PEP
most common causes of a breast lump in order of occurrence
relative frequency
1

< 35 years
fibrocystic changes

35-50 years
fibrocystic changes

> 50 years
carcinoma

2
3
4
5

fibroadenoma
mastitis
carcinoma
fat necrosis

carcinoma
fibroadenoma
mastitis
fat necrosis

fibrocystic changes
fat necrosis
mastitis

mammogram is suspicious
fine-needle biopsy or core aspirate; however, if negative may still proceed to biopsy
excision biopsy and obtain pathology
Stage I
tumour < 2cm
no nodes

Stage II
tumour < 5cm
nodes not fixed

Stage III
tumour > 5cm or
tumour any size plus
- invading skin
- invading chest wall

Stage IV
metastases

if positive biopsy, then

staging: 1) CXR; 2) abdo US/CT + LFTs; 3) Bone scan
local therapy: lumpectomy/axillary node dissection/radiotherapy or
mastectomy/axillary node dissection
adjuvant therapy:
estrogen positive:
node negative: tamoxifen +/- chemo (nothing if <1cm)
node positive: tamoxifen +/- chemo
estrogen negative:
node negative: chemo (nothing if < 1cm)
node positive: chemo
therapy for metastatic disease
chemotherapy
hormonotherapy
radiotherapy especially for bony mets
surgery
in situ breast carcinoma = stage I (follow above for local and adjuvant therapy)

VASCULAR
1.

Claudication

60 male with claudication. Physical examination for PVD (upper and lower extremities). Physical only.
SURGERY
PEP:

1. ECG is normal. Ask you to interpret it.

2. What two investigations would you order for PVD (dopplers with ABI, angiography)
3. Five risk factors for PVD (Hypertension, diabetes, smoking, hypercholesterolemia,
CAD, CVD, ESRD)

65ish man w leg pain. Peripheral vascular exam. WRITTEN: What are three tests you would order?
Woman with claudication
History
pain: location, OPQRST
reproducible claudication distance
relieved by rest (usually 5-10 minutes)
previous history of pain
rest pain, night pain, ulcers, gangrene
cardiac risk factors
past medical history
family history
medications
allergies
social: smoking, alcohol
Differential diagnosis: spinal stenosis, disc disease, arthritis, venous disease
Investigations: Ankle-brachial index <0.9 is abnormal, Angiogram = gold standard
PEP
management
conservative: stop smoking, control DM, hypertension, foot care, exercise
when to do surgery
critical ischemia < 0.5 (rest pain, night pain, ulcers, gangrene)
subjective disability severe (ie. walks less than 1block)
types of surgery
transluminal angioplasty
inflow procedures for aortoiliac disease
endarterectomy
profundoplasty
femoropopliteal bypass

PLASTICS
1.
2.
3.

hand exam
face exam (trauma)
carpal tunnel

Patient with a palmar gash - examination of the hand

1. Inspection - laceration, swelling, erythema, deformity, muscle atrophy, foreign bodies
2. Nerves
a. Radial - sensory - dorsum of 1st web space
- motor - extend wrist (extensor carpi radialis)
- "hitch hike" (extensor pollicus longus)
b. Ulnar - sensory - ulnar 1.5 digits, pad of pinky finger
- motor - flex DIP of little finger (flex dig profundus)
- froment sign - pull paper between index/thumb (adductor pollicus)
- spread fingers out - 1st dorsal interossei
c. Median - sensory - radial 3.5 fingers, index finger pad
- motor - thumb to ceiling (abductor pollicus)
- flex distal IP index (flexor digitorum profundus)
- pinky and thumb together (opponens)
--> check digital nerves with 2 point discrimination and light touch
3. Vascular
- feel for pulses
- capillary refill, skin color and temperature
- allen's test
4. Flexor tendons (palmar)
- flexor dig. profundus, isolate and flex DIP
- flexor dig. superficialis, isolate and flex PIP
- intrinsics, isolate and flex MCP
5. Extensors (dorsal)
- extensor dig communis - MCP extension
- intrinsics - PIP and DIP extension
--> never test tendons against resistance if suspect tendon laceration, let patient actively move the
joints themselves
6. Palpation
- for tenderness, fractures
ASIDE - Flexor tendon sheath infection = Kanavel's 4 cardinal signs
1. symmetrical swelling of the digit
2. tenderness along flexor tendon sheath
3. flexed or semi-flexed attitude of finger
4. sever pain on passive extension DIP
34 yo male drug addict assaulted while trying to rob a convenience store - examine face
Examination of the face
1. Inspection
- symmetry, bruising, swelling, deformity, bleeding from orifices, lacerations, proptosis, breathing,
exophthalmos, enophthalmos, septal hematoma, malocclusion
- basal skull fracture - lefort III - racoon eyes, battle sign, CSF otorrhea, hemotympanum
2. Palpation
a. deformities in skull --> go from top to bottom
- supraorbital rim/infraorbital rim
- maxilla, mandible/arches, nasal bones
- ?step deformity, crepitus, tender
b. intraoral exam

- grab front teeth and pull (lefort III)

- tear in mucosa/gingiva (mandibular)
3. Cranial Nerves, focusing on V
4. Feel for carotid
5. GCS, and look in ear
PEP - radiologic investigations
Structure
Mandible

Nasal bones
Zygomatic and orbital

Maxilla

Best xray
PA of mandible
Townes view (AP)
lateral obliques
Panorex
no xray required
CT scan is investigation of choice
Water's view
Caldwell's view
submento-vertex
CT scan axial and coronal

Facial trauma + diplopia examine

Inspection
Mandible: malocclusion, crepitus, dislocation, deformity, ?
Maxilla: swelling, malocclusion, crepitus, donkey face (II), CSF rhinorrhea (III)
Zygoma: periorbital ecchymoses, flat cheek
Nose: nasal bone fracture
Blowout: up/down gaze, vertical diplopia, enopthalmos, pseudoptosis, infraorbital nerve
hypesthesia/anesthesia

70 yo with numbness and tingling in her right hand - hx and px

top 3 ddx:
carpal tunnel
cervical spinal disease: stenosis, disc disease, OA
thoracic outlet syndrome (including Pancoast tumour)
TIA
ID: age, sex occupation/hobbies (repetitive strain)
HPI:
Onset: sudden vs gradual, activity at time of onset
Position: dermatomal distribution? Other areas affected on body? Other hand?
Provocation/alleviation: with position, time of day (i.e. nocturnal pain), movement, medications, neck
movement, relieved by shaking? (carpal tunnel), pain down arm in nerve root distribution worse with neck
extension (cervical disc syndrome)
Radiation: from neck/shoulder, into fingers, etc.
Associated symptoms: weakness of hand, pain, clumsiness of hand, decreased ROM of wrist/fingers,
dysesthesias, swelling, erythema, hx of hemiparesis/dysarthria, visual changes, headache (migraine aura),
neck pain
Temporal profile: progression of symptoms over time
Risk factors: (OA) hx of joints affected by arthritis? Hx of TIA/CVA/other evidence vascular disease,
presence of medical disease associated with nerve entrapment (below), pattern of sleeping (i.e. sleep with
hand under head? - ulnar)

PMHx
medical (the following are associated with nerve entrapment syndromes):
-endocrine: hypothyroid, diabetes, acromegaly
-autoimmune: rheumatoid arthritis, vasculitis
-amyloidosis (multiple myeloma)
2) Surgical
Meds, smoking, allergies, alcohol
SHx: functional limitation on ADLs, etc
Physical Examination
Examination of the hand:
Inspection: muscle bulk, fasciculations, muscle wasting in advanced carpal tunnel syndrome (thenar
eminence, especially abductor pollicis brevis), inflammation
Sensory: search for dermatomal distribution of symptoms
Motor (power):
grip
pinch
finger adduction - median nerve (C7-T1)
finger abduction - ulnar nerve (C8-T1)
wrist flexion - median nerve, (C6,7)
wrist extension wrist - radial nerve (C6-8)
thumb adduction
thumb abduction
thumb opposition - median nerve (C8 - T1)
Examination of C-spine and shoulder warranted (see spine exam above)
Shoulder examination:
Inspection: obvious inflammation
Palpation: shoulder and surrounding structures
Function (ROM): passive, then active
-shoulder movements are abduction, adduction, flexion, extension, internal and external rotation
-movements occur at glenohumoral, thoracoscapular, acromioclavicular and sternoclavicular joints
(glenohumoral = shallow ball + socket, so depend on rotator cuff muscles)
Flexion: 180 degree arc normal
Extension: back straight arm motion 30-60 degrees
Abduction: fix scapula, lift arm laterally until scapula rotates 90 degrees
Internal and External rotation: flex elbow at 90 degrees against side, palm up and swing forearm to chest
for internal, swing out for external.
Special tests:
Tinels sign (carpal tunnel) - percussion over flexor retinaculum and see if elicits tingling sensation

ENT
1.

thyroid

Examine midline neck mass thyroid ca

Inspection of neck
JVP
Surgical scars
Enlarged cervical lymph nodes
Goitre

Palpation (from front or back) make sure water around

Seat the patient comfortably
Comment first on exopthalmos
Palpate isthmus and both lobes
Stand behind patient, whose neck is slightly extended. Put both hands around neck. Use left
hand to push trachea to right identify thyroid cartilage - ask for swallow feel for thyroid
against right sternomastoid repeat on left
Size, mobility, texture, tenderness
Extra (cervical nodes, carotids, tracheal deviation)

Auscultate over gland for bruits

Test sternomastoid function ( may be infiltrated in thyroid malignancy)
? Thyroid function
Eye Signs
Lid lag, exopthalmos, lid retraction, EOM
Hands
Pulse (tachy/ a-fib), tremor, clubbing, palmar erythema, supinator jerks
Skin
Pretibial myxedema
Ankle jerks

thyroid exam, approach to thyroid nodule

1) Inspect: tip the pts head back a bit & inspect the region below cricoid cartilage for the thyroid
2) Inspect with water: ask the patient to sip some water and extend the neck again and swallow, noting the
contour and symmetry of the thyroid
Palpate: from behind, place fingers of both hands on patients neck so your index fingers are just below the
cricoid (dont have them tip head back or muscles get in way)
Palpate with water: feel for any glandular tissue rising under your fingers. Isthmus often palpable but not
always. Note size, shape and consistency of gland, and the presence of nodules or tenderness. (each lateral
lobe is normally the size of bottom of thumb)
Auscultate: if thyroid enlarged you must listen for a bruit
Thyroid Nodule
(
Malignant

(
FNA Biopsy
(
Follicular neoplasm or suspicious

(
Benign

(
thyroid scan
Cold

Surgery high risklow risk

Hot

Observe

T4 therapy
maybe T4 tx
failure to regress
rebiopsy or excise

regression
continue T4