Neck lumps, swellings

Computed tomography Cancer and metastases

Useful in staging

PCR, polymerase chain reaction.

OSCE example 1: Hoarseness

Mr Smith, 65 years old, presents with hoarseness.

Please take a history from the patient

• Introduce yourself and clean your hands.

• Invite the patient to describe the presenting symptoms, using open questioning.

• Take a detailed history of the presenting symptoms, asking specifically about onset, progression, fluctuation or constancy, provoking factors (work,

singing, shouting) and weak or croaky voice. Enquire about associated cough, shortness of breath, throat pain, ear pain, dysphagia or weight loss.

• Ask about relevant past history, including previous neck surgery, neck trauma, prolonged intubation, reflux disease and significant systemic

conditions, including neurological problems.

• Enquire about drug history: specifically, recent courses of antibiotics (laryngeal candidiasis), anticholinergics (causing dry throat) or angiotensinconverting enzyme inhibitors (causing chronic dry cough).

• Ask about social history, including profession (singer, teacher), smoking and alcohol consumption.

• Address any patient concerns.

• Thank the patient and clean your hands.

Summarise your findings

The patient is a heavy smoker and reports slowly progressive hoarseness associated with breathlessness and a dry cough.

Suggest a diagnosis

This history suggests recurrent laryngeal nerve damage from a bronchial carcinoma. The differential diagnosis would include laryngeal carcinoma.

Suggest initial investigations

Full ear, nose and throat examination, including oral cavity, throat and neck, with a chest X-ray to exclude a bronchial carcinoma at the left hilum

causing recurrent laryngeal nerve palsy. Persistent hoarseness (>3 weeks) requires referral for laryngoscopy to exclude laryngeal malignancy.

Fig. 9.28 Thyroglossal cyst.

Investigations • 191

9

OSCE example 2: Neck lump

Mrs Lewis, 55 years old, presents with a lump just under her left ear at the angle of her jaw.

Please examine her neck lump

• Introduce yourself and clean your hands.

• Inspect the neck for scars or swelling. If a neck lump is visible, describe its size, shape and site, as well as any skin changes. If it is in the midline,

ask the patient to swallow and stick out their tongue.

• Ask if the lump is painful and if the patient minds you examining it.

• Palpate the lump to assess consistency, edge, fixation to deeper structures, tethering to the skin, warmth, fluctuance, pulsatility and

transillumination.

• Palpate the anterior and posterior triangles of the neck, and the parotid region.

• Examine the oral cavity, throat, nose and ears (as potential primary sites of infection or malignancy that might be causing the neck mass).

• Assess facial nerve function if you suspect a parotid mass.

• Thank the patient and clean your hands.

Summarise your findings

Examination confirms a firm, non-tender, mobile lump about 1 cm in diameter behind the angle of the jaw on the left.

Suggest a diagnosis

The most likely diagnosis is a pleomorphic salivary adenoma in the tail of the parotid.

Suggest investigations

Ultrasound scan with or without fine-needle aspiration.

Integrated examination sequence for ear, nose and throat disease

• Position the patient: on an examination couch with the upper body at 45 degrees and neck fully exposed.

• Examine the ears:

• Inspect: pinna skin, shape, size, position, deformity, scars.

• Palpate: pinna, tragus, mastoid.

• Otoscopy: external auditory canal (swelling, discharge), tympanic membrane (red, perforated).

• If there is hearing loss: whispered voice test and tuning fork tests.

• If there are balance symptoms: vestibular examination, including Dix–Hallpike.

• Examine the nose:

• Inspect:

– External nose (swelling, bruising, skin changes, deformity).

– Anterior nasal septum (swelling, visible vessels, crusting ulceration, septal perforation). Exclude septal haematoma in nasal trauma.

– Inferior turbinates (hypertrophy, swelling, polyps).

• Palpate:

– Nasal bones (bony or cartilaginous deformity).

– Airway patency using metal spatula.

• Examine the mouth and throat:

• Listen to the voice (rough, breathy, wet, muffled, nasal escape).

• Remove any dentures.

• Inspect:

– Oral cavity, oropharynx.

– Mucosal discoloration, inflammation, ulceration, masses, opening of parotid and submandibular ducts.

– Hard palate for cleft, abnormal arched palate, telangiectasia.

– Soft palate for cleft, bifid uvula, swelling or lesions.

– Tonsils, noting size, symmetry, colour, pus or membrane.

• Palpate:

– Any lesion, identifying characteristics.

– Base of tongue or tonsils if asymmetrical.

– Parotid and submandibular ducts, feeling for stones.

• Examine the neck:

• Inspect:

– Scars, skin changes.

– If there is midline swelling, ask the patient to swallow and stick out their tongue.

• Palpate:

– Anterior and posterior triangles of the neck and parotid region.

– If there is a neck lump, note size, site, shape, consistency, edges, attachments, tenderness, warmth, pulsatility, transillumination.

– If there is a parotid lump, assess the facial nerve.

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10

The endocrine system

Anna R Dover

Nicola Zammitt

The thyroid 194

Anatomy and physiology 194

The history 194

Common presenting symptoms 194

Past medical, drug, family and social history 196

The physical examination 197

General examination 197

Thyroid gland 197

Eyes 198

The parathyroids 198

Anatomy and physiology 198

The history 198

Common presenting symptoms 198

Past medical, drug, family and social history 199

The physical examination 199

The pituitary 200

Anatomy and physiology 200

The history 200

Common presenting symptoms 200

Family history 200

The physical examination 200

The adrenals 201

Anatomy and physiology 201

The history 201

Common presenting symptoms 201

Past medical and drug history 202

The physical examination 202

The gonads 204

Anatomy and physiology 204

The history 204

Common presenting symptoms 204

Diabetes 205

Anatomy and physiology 205

The history 205

Common presenting symptoms 205

Past medical, drug, family and social history 205

The physical examination 206

OSCE example 1: Neck swelling 209

OSCE Example 2: Diabetic feet 209

194 • The endocrine system

10.1 Common clinical features in endocrine disease

Symptom, sign or problem Differential diagnoses

Tiredness Hypothyroidism, hyperthyroidism, diabetes mellitus, hypopituitarism

Weight gain Hypothyroidism, PCOS, Cushing’s syndrome

Weight loss Hyperthyroidism, diabetes mellitus, adrenal insufficiency

Diarrhoea Hyperthyroidism, gastrin-producing tumour, carcinoid

Diffuse neck swelling Simple goitre, Graves’ disease, Hashimoto’s thyroiditis

Polyuria (excessive thirst) Diabetes mellitus, diabetes insipidus, hyperparathyroidism, Conn’s syndrome

Hirsutism Idiopathic, PCOS, congenital adrenal hyperplasia, Cushing’s syndrome

‘Funny turns’ or spells Hypoglycaemia, phaeochromocytoma, neuroendocrine tumour

Sweating Hyperthyroidism, hypogonadism, acromegaly, phaeochromocytoma

Flushing Hypogonadism (especially menopause), carcinoid syndrome

Resistant hypertension Conn’s syndrome, Cushing’s syndrome, phaeochromocytoma, acromegaly

Amenorrhoea/oligomenorrhoea PCOS, hyperprolactinaemia, thyroid dysfunction

Erectile dysfunction Primary or secondary hypogonadism, diabetes mellitus, non-endocrine systemic disease, medication-induced

(e.g. beta-blockers, opiates)

Muscle weakness Cushing’s syndrome, hyperthyroidism, hyperparathyroidism, osteomalacia

Bone fragility and fractures Hypogonadism, hyperthyroidism, Cushing’s syndrome, primary hyperparathyroidism

PCOS, polycystic ovary syndrome.

Endocrine glands synthesise hormones that are released into

the circulation and act at distant sites. Diseases may result

from excessive or inadequate hormone production, or target

organ hypersensitivity or resistance to the hormone. The main

endocrine glands are the pituitary, thyroid, adrenals, gonads

(testes and ovaries), parathyroids and the endocrine pancreas.

With the notable exception of the pancreatic islet cells (which

release insulin) and the parathyroids, most endocrine glands

are themselves controlled by hormones released from the

pituitary.

Since hormones circulate throughout the body, symptoms and

signs of endocrine disease are frequently non-specific, affecting

many body systems (Box 10.1). Often, endocrine disease is

picked up incidentally during biochemical testing or radiological

imaging.