PF ENDOCRINE

1. Introduction, confirmation, informed consent Thyroid Examination

2. Pasien dipersilahkan tiduran & cuci tangan (6 langkah WHO) The thyroid gland sits at the front of the neck and produces endocrine hormones into the
3. General bloodstream. Sometimes the gland can produce too much (hyperthyroid) or too little hormone
a. Kesadaran: compose mentis (hypothyroid) which results in a patient needing treatment. There are certain signs and
b. GCS symptoms that the patient may present with and it is these that you are examining the patient for
c. Sakit: ringan / sedang / berat in this station.
d. Habitus: atletikus / estenikus / piknikus In OSCEs this station may start in a number of ways. You may be given a history of a hyper- or
e. Tanda" dehidrasi: trugor kulit hypothyroid patient, or you may be asked to examine the patient’s neck or thyroid gland. Either
4. TTV way you should approach the situation systematically and not jump straight into feeling the neck.
HR Frequency (n: 60 - 100) Subject steps
Rhythm 1. Wash your hands and introduce yourself to the patient. Clarify the patient’s identity. Explain
Simetris / equal the procedure and gain the patient’s consent.
Kuat angkat Wash your hands
2. Perform an initial observation of the patient.
BP n: 120/60 mmHg o Do they seem abnormally hyper- or hypoactive?
dilakukan saat standing & tiduran (DM) --> hypotensi postural o Do they appear sweaty?
Trousseau's sign: systolic + 20mmHg --> tunggu 3 min --> tangan/carpal spasm (kyk mulut bebek)--> (+) Hypercalemia o What condition is their skin and hair?
RR Frequency (n: 12-20) o Does their voice sound normal?
Pola pernafasan Report any abnormalities to the examiner.
3. A dysfunctioning thyroid gland may give stigmata of disease in many places, so as always,
Temp n: 36.5-37.2
it is best to start with the hands. You should first feel the hands for any sweating. Look for any
5. HEAD tremor – placing a piece of paper on the backs of the patient’s outstretched hands may show this. Check
a. Face: the nails for any thyroid acropatchy – similar to clubbing, or onycholysis – where the nail comes away
i. Normocephali
from the nail bed. You should also observe for any palmar erythema which may occur in
ii. Syndrome facies
hyperthyroidism.
iii. Jerawat / oily skin
Inspect for tremor in the hands
iv. Hirsutism: facial hair pd female
4. Next you should feel the pulse. It may be tachy or bradycardic if a thyroid condition is
v. Chvostek sign: ketuk antar dpn telinga & cheek --> merengut --> (+) Hyprcalcemia
present.
b. Eyes:
Feel the pulse
i. Exophthalamus: bbs menggunakan exophthalammeter (klo minimal) --> Hyperthyroid
5. Now move onto the neck. Observe it as a whole but pay particular attention to the area of
ii. Fundus: retinopathy --> DM & Acromegaly
the thyroid gland. You should look from the front and the side looking for any obvious
c. Hidung
abnormalities, scars or swellings.
i. Simetris
Observe the neck
ii. Cuping hidung
6. Hand the patient a glass of water and observe them as they take a drink. Watch the
d. Mouth
movement of any swellings as they drink as this can help to differentiate between different
i. Tongue enlargement --> Gigantism
causes.
ii. Buccal pigmentation: di bag pipi dalem --> Addison's disease
Observe the neck as the patient drinks
6. NECK
7. Next you should feel the gland. The approach is from behind so always tell the patient what
a. Buffalo Hump --> Cushing's disease
you will be doing and that you will be behind them. Warn them again the moment before you
b. Palpasi supraclavicular utk fat pads --> Cushing's disease
actually touch their neck.
c. Webbed neck --> Turner Syndrome
Palpate the thyroid gland
d. Benjolan disekitar KGB
8. Palpate the entire length of both lobes of the gland as well as the isthmus. Note any
7. THYROID
swellings or abnormal lumps. You should note the shape and consistency of any lumps as well
a. General
as whether they are tender or mobile. You should also examine while the patient drinks to
b. TTV
assess whether the lump moves with swallowing.
c. Tangan
9. Whilst still behind the patient, take the opportunity to examine the cervical lymph nodes.
d. Liat dari dpn dan samping --> ada perbesaran gk
You should also examine the eyes from behind and above to look for any exophthalmos –
e. Pasien diminta minum --> liat benjolannya bergerak ato gk
another sign of hyperthyroidism.
f. Palpasi --> lokasi (bilateral/lateral), ukuran, konsistensi (keras/gk), permukaan (mulus/nodul brp), nyeri gk, suhu (pake
Examine the cervical lymph nodes
punggung tangan, benjolannya mobile ato gk
10. Finally you should auscultate the thyroid. A bruit, a sign of increased blood flow, may be
g. Auskultasi --> dengerin ada bruit ato gk
heard in hyperthyroidism.
8. THORAX (ANTERIOR)
Auscultate the thyroid
a. INSPEKSI
Thank your patient and report your findings to the examiner. An extension to this station could
i. Scar , luka, bekas operasi
be thyroid function results interpretation.
ii. Discoloration
iii. Symmetry
Source : https://www.medistudents.com/osce-skills/thyroid-examination
iv. Bentuk abnormal
1) Barrell chest
2) Pectus excavatum (<) From <https://learn.uph.edu/course/view.php?id=24353&section=42>
3) Pectus carinatum (>)
v. Retraksi ICS / supraclavicular
vi. Ichthus cordis berdenyut: ICS 5, midclvicular
b. PALPASI
i. Perkembangan dada: simetris
ii. Tactile fermitus (8 titik @2x; 77): getaran simetris diseluruh lapang paru
iii. Ichthus cordis: trill (getaran) / heave (berdenyut)
c. PERKUSI
i. Paru: bunyi sonor diseluruh lapang dada
ii. Batas paru:
1) Paru-hepar: ICS 5-6, midclavicular dextra (sonor --> dull)
2) Paru-lambung: ICS 6-8, midclavicular sinistra (sonor --> tymphani)
iii. Batas jantung
1) Kanan: ICS 4-5, sternalis dextra [batas paru hepar, naik 1 ICS, ke medial] (sonor --> dull)
2) Kiri: ICS 4-5, midclavicular sinistra [batas kanan, ke kiri] (dull --> sonor)
3) Atas: ICS 2, parasternal sinistra
d. AUSKULTASI
i. Paru: suara pernafasan normal (vesikular), suara tambahan stridor/rales/wheezing
ii. Katup Jantung: Terdengar S1-S2 reguler/irreguler; suara tambahan S3/S4/murmur
1) Aorta: ICS 2, parasternal dextra
2) Pulmonal: ICS 2, parasternal sinistra
3) Trikuspid: ICS 4, miclavicular sinistra
4) Mitral: ICS 4, paasternal sinistra
9. ABDOMEN (ANTERIOR)
a. ! BEND KNEES !
b. INSPEKSI
i. Scar, luka, bekas operasi
ii. Discoloration
iii. Distensi
iv. Perut cembung --> asites
v. Darm contour & darm steifung
vi. Caput medusa
vii. Purple striae
viii. Cullen & grey sign --> Pancreatitis
c. AUSKULTASI
i. 9 regio / 4 quadrant / 2 titik (epigastric & mcburney)
1) Bising usus: 8-20
2) Metalic sound
ii. Bruit: aorta abdominalis & renalis (sekitar paraumbilical)
d. PERKUSI
i. 9 regio: tymphani
ii. Shifting dullness
e. PALPASI
i. Light: nyeri tekan & lepas
ii. Deep: massa
iii. Hepar:
Kanan R Iliac --> R arcus costae
Kiri Umbilica --> prosesus siphoideus
1) Brp jari
2) Permukaan licin / bernodul
3) Tepi tajam / tumpul
4) Konsistensi kenyal / keras
5) Nyeri tekan
iv. Spleen
R Iliac --> L Arcus costae
1) Schuffner 1-8
v. Ballotement --> hydronefrosis
vi. Fluid wave --> asites
10. THORAX & ABDOMEN (POSTERIOR)
a. INSPEKSI
i. Scar, luka, bekas operasi
ii. Memar / discoloration
b. AUSKULTASI
i. Paru: antara scapula (8 titik): suara vesikular diseluruh lapang paru; suara tambahan stridor/rales/wheezing
c. PERKUSI
i. Paru: antara scapula, ikutin bentuknya : suara sonor diseluruh lapang paru
ii. Ketuk CVA: costovertebra angle --> nefrolithiasis
11. GENITALS
a. Atrophy
b. Virilisation: clitoris membesar, suara jd berat, tumbuh jakun pd females

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 b. Virilisation: clitoris membesar, suara jd berat, tumbuh jakun pd females
12. EXTREMITY
a. Acanthosis nigricans: lipatan" tubuh makin gelap --> DM
b. Axillary hair loss
c. HANDS:
i. Oversized/ jari pendek
ii. Hangat / lembab
iii. Tremor (bs pake kertar taro di tangan, posisi both arms lurus ke depan)
iv. Palmar erythema
v. Pigmentasi
vi. Clubbing finger
vii. CRT
d. Muscle weakness: bandingin R & L
e. Sensorik kasar: pake jarum, pasien merem, tanya kersa & dmn, bandingin R & L

1. Introduction, confirmation, informed consent

2. Pasien dipersilahkan tiduran & cuci tangan (6 langkah WHO)
3. General
a. Kesadaran: compose mentis
b. GCS
c. Sakit: ringan / sedang / berat
d. Habitus: atletikus / estenikus / piknikus
e. Tanda" dehidrasi: trugor kulit
f. Berat badan & tinggi badan
4. TTV
HR Frequency (n: 60 - 100)
Rhythm
Simetris / equal
Kuat angkat
BP n: 120/60 mmHg
dilakukan saat standing & tiduran (DM) --> hypotensi postural
RR Frequency (n: 12-20)
Pola pernafasan
Temp n: 36.5-37.2
5. Rambut
a. Rontok/rapuh ( gmpang rontok
b. Rambut kasar/kering
6. Wajah
a. Moon face / edema
7. Mata
a. Konjunctiva anemis
b. Sclera anemis
c. Exophthalmus --> liat dr dpn / samping
d. Lid retraksi / lid lag--> pasien liat atas & bawah --> kelopak mata pasien lambat geraknya/gk ikut gerak & tanya ada pandangan
ganda tdk
liat dari atas/dpn --> dari atas skleranya keliatan bgt
e. Kemosis --> penebalan/edema dari konjungtiva --> iritasi di konjungtiva (jd bengkak) (karena gk bisa kedip jd mata kering&irritation)
8. Hidung
a. Simetris
b. Cuping hidung
9. Mulut
a. Oral hygiene
b. Perbesaran lidah
c. Pembengkakan pd tonsil
10. Leher
a. Inspeksi (dr dpn & samping)
a. Bengkak gk
b. Pasien minta minum/menelan, ikut gerak gk benjolannya
c. Kelainan kulit/scar
d. Eritema
e. Diskolorasi
f. Prominent pain gk
b. Palpasi (dibawah tulang trikoid) (dari dpn (pake jempol)/ dari belakang )
a. Lokasi (lateral/bilateral)
b. Bentuk
c. Permutaan --> halus/ nodul" (multinoular/soliter)
d. Konsistensi (keras/lembut)
e. Mobile/imobile
f. Temp -->pake punggung tangan
c. Auskultasi di kanan kiri --> bruit
d. KGB --> ada perbesaran/benjolan gk
a. Postauricular
b. Preauricular
c. Submandibula
d. Submental
e. Cervical
f. Supraclabicular
g. Subclaricular
h. Axilla
e. Pemberton sign --> pasien angkat tangan --> tunggu beberpa menit --> muka pasien jd merah (obstruksi vena karena tiroid
membesar)
11. Thorax
a. INSPEKSI
i. Gynecomstia
ii. Scar , luka, bekas operasi
iii. Discoloration
iv. Symmetry
v. Bentuk abnormal
1) Barrell chest
2) Pectus excavatum (<)
3) Pectus carinatum (>)
vi. Retraksi ICS / supraclavicular
vii. Ichthus cordis berdenyut: ICS 5, midclvicular
b. PALPASI
i. Perkembangan dada: simetris
ii. Tactile fermitus (8 titik @2x; 77): getaran simetris diseluruh lapang paru
iii. Ichthus cordis: trill (getaran) / heave (berdenyut)
c. PERKUSI
i. Perkusi manubrium sterni (ada perubahan suaranya gk)
ii. Paru: bunyi sonor diseluruh lapang dada
iii. Batas paru:
1) Paru-hepar: ICS 5-6, midclavicular dextra (sonor --> dull)
2) Paru-lambung: ICS 6-8, midclavicular sinistra (sonor --> tymphani)
iv. Batas jantung
1) Kanan: ICS 4-5, sternalis dextra [batas paru hepar, naik 1 ICS, ke medial] (sonor --> dull)
2) Kiri: ICS 4-5, midclavicular sinistra [batas kanan, ke kiri] (dull --> sonor)
3) Atas: ICS 2, parasternal sinistra
d. AUSKULTASI
i. Paru: suara pernafasan normal (vesikular), suara tambahan stridor/rales/wheezing
ii. Katup Jantung: Terdengar S1-S2 reguler/irreguler; suara tambahan S3/S4/murmur
1) Aorta: ICS 2, parasternal dextra
2) Pulmonal: ICS 2, parasternal sinistra
3) Trikuspid: ICS 4, miclavicular sinistra
4) Mitral: ICS 4, paasternal sinistra

12. Extremmitas
a. Tremor --> tangan lurus kedpn pronasi, taro kertas diatasnya
b. Kuku kasar gk (brittle nail
c. Onycholysis
d. Proximal myopathy --> pasien angkat tangan, kuat gk
e. Telapak tangan --> hangat / lemab / palmar erytema/ clubbing finger / crt kulit kering ato gk
f. Kaki --> mixoedema / kulit kering /kulit kemerahan
g. Kekuatan otot
i. Atas --> panco
ii. Bawah --> angkat kaki , ditahan
h. Reflex --> Hypo/hyper reflex
a. Bicep

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a. Bicep
b. Trieps
c. Patella
d. Achilles

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