Thyroid Gland and Tympanic Membrane Assessment Essay

South University

Abstract

The tympanic membrane and thyroid gland function are assessed using laboratory values, inspection and palpitation.

Assessment of the Thyroid Gland and Tympanic Membrane

Patients with abnormalities of the thyroid gland may have a multitude of presenting symptoms. Those symptoms are usually related to either an abundance of circulating thyroid hormone (hyperthyroidism), or a deficiency of circulating thyroid hormone (hypothyroidism). Thyroid disease symptoms may also be related to an abnormal enlargement of the thyroid gland such as a goiter or nodule. Symptoms related to hyperthyroidism include weight loss, anxiety or nervousness, increased sweating, diarrhea, palpitations, muscular weakness and heat intolerance. Symptoms of hypothyroidism usually include fatigue, weight gain, depression, lethargy, dry skin, cold intolerance, voice changes, changes to menses and muscle cramps. Enlargement of the thyroid gland (goiter), or thyroid nodules may present symptoms of hypothyroidism or hyperthyroidism along with symptoms specific to the enlarging gland such as neck swelling, neck mass, dysphagia, neck pain or hoarseness. Boston: Butterworths (1990) states, “As the symptoms of hyper-or hypothyroidism are nonspecific, often they are attributed to other medical or psychiatric illnesses.” Because the symptoms are nonspecific, diagnosing hypo-hyperthyroidism can be a difficult task.

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The following is a patient health assessment history completed on Mrs. Snow, a fifty-two years old, white, female that presents to the clinic with complaints of fatigue, weight gain, hoarseness, difficulty swallowing and swelling in the neck.

Biographic Data—52 YOA married, white English speaking, female, DOB 03/10/1965, currently employed as a high school math teacher, Mrs. Snow is ill appearing, but seems reliable for the information provided. Thyroid Gland and Tympanic Membrane Assessment Essay.

Reason for Seeking Care—Mrs. Snow states, ‘I have just been so tired, and somehow I’ve gained twelve pounds even though I seem to be unable to swallow meat here lately.”

Present health or history of present illness—Location: Mrs. Snow states the “front of my neck is swelling.” She reports the swelling started a month ago and that is when she noticed it was harder to swallow and talk. She also stated “I weighed 154lbs a few weeks ago, and now I’m up to 167.” Mrs. Snow states, “I’m so tired that I haven’t even worked in the last two weeks.” Setting: Swelling was noticed one morning, she denies any trauma or heavy lifting

Associated Factors: difficulty swallowing, fatigue, weight gain, hoarseness, patient is currently a smoker current medications include Zoloft 50mg po HS, and Multivitamin daily

Past History—childhood history of Chicken Pox no other significant childhood illnesses history of depression and frequent UTI, past hospitalizations include treatment in 2011 by Dr. J Morgan for depression as an inpatient at Greenleaf Psychiatric facility with antidepressants and therapy. OB—Grav1, Term 1, Preterm 0, Ab 0, Living 1 Healthy female child 7lb 2oz, vaginal delivery without complications

Immunizations current including Flu vaccine 12/01/2017

Medication Reconciliation–Zoloft 50mg HS, MVI daily Patient has a 20 pack year history of smoking

Family History—significant for thyroid goiter in mother

SOAP NOTE:

S=Mrs. Snow comes in with a month long history of swelling in the anterior portion of the neck, fatigue, difficulty swallowing, weight gain, hoarseness. She states, “The swelling never goes away, and I’ve been too tired to go to work.” Weight per patient a few weeks ago was 154lbs, Family History significant for goiter in mother

O= weight 167lbs, thyroid gland palpated using the posterior approach with enlargement noted, bruit auscultated BP 108/52, Pulse 54, afebrile, TSH-8uU/ml FT4-2.0ug/dl.

A=Hypothyroidism, goiter

P=Rx Synthroid 1.6 mcg/kg po daily, Outpatient Radioactive Iodine Uptake, follow up two weeks

Laboratory tests used to diagnose disorders of the thyroid gland include thyroid function test and radioactive iodine uptake measures. The thyroid function tests specifically measurements of the free T4 levels and TSH levels are used to assist with diagnosis of hypo-hyperthyroidism. T4 or thyroxine is the major hormone secreted by the thyroid gland. The amount of T4 produced is controlled by TSH (thyroid stimulating hormone). TSH is made by the pituitary gland. The pituitary adjusts the secretion of TSH based on the levels of T4 in the blood. If the T4 level is low, the pituitary increases the levels of TSH making the thyroid gland aware that it needs to secrete more T4. When the T4 level goes above a certain level, then the pituitary gland stops secreting TSH.

Normal TSH levels are 0.5-6uU/ml. A high TSH level indicates an inactive thyroid or hypothyroidism. A low TSH level indicates an overactive thyroid gland or hyperthyroidism.

T4 circulates in the blood either bound to proteins or in a free state. The Free T4 measurement is the most accurate to diagnose thyroid gland functioning. An elevated FT4 indicates hyperthyroidism, and a low FT4 indicates hypothyroidism. Normal FT4 values are 4.6-12ug/dl.

Radioactive iodine uptake measures the activity required by the thyroid to pull iodine from the blood stream in order to make the hormone T4. The patient swallows iodine, that is radioactive, and the radioactive iodine molecules can be tracked in the body. If the RAIU is high in the thyroid gland this is indicative of hyperthyroidism. If the RAIU is low in the thyroid gland then the patient is considered to have hypothyroidism.

The thyroid gland can be examined using an anterior or posterior approach. The thyroid gland should also be inspected for any signs of swelling. Ask the patient to tilt their head back and sip water, the thyroid gland should move up when the patient swallows then fall back to a resting point. Be sure to notice any signs of enlargement, or nodule. Thyroid Gland and Tympanic Membrane Assessment Essay.

In order to use the posterior approach to examine, have the patient sit upright bending their head slightly forward and to the right. The examiner stands behind the patient using the fingers of your left hand to move the trachea slightly to the right displacing the trachea. While displacing the trachea with your left hand, curve your right hand between the trachea and slightly retract the sternomastoid muscle. While performing the above steps, have the patient take a sip of water. Your right hand should feel the thyroid gland move up with the trachea and larynx while the patient swallows. After examining the patient’s right side of the neck, repeat these steps on the patient’s left side of the neck to complete the exam. In an adult you should not be able to palpate the thyroid gland. If you can palpate anything, be sure to note enlargement, symmetry, or the presence of nodules.

The anterior approach can be difficult for the inexperienced provider to use. Just as with the posterior approach, have the patient tilt their head slightly forward and to the right. The examiner will stand in front of the patient rather than behind using the anterior approach. Use your right thumb to displace the trachea, while hooking your left thumb and fingers around the sternomastiod muscle. Have the patient swallow and assess for enlargement, symmetry, or the presence of nodules. Repeat the process on the patient’s left side as well.

If the thyroid gland is enlarged, it should also be auscultated for a bruit. If a bruit, or whooshing sound, is heard with the bell of the stethoscope placed over the gland, it indicates hyperplasia of the thyroid. A bruit is not normally heard on auscultation of the thyroid gland.

The following is a health assessment history completed on Mr. Brown. He is a twenty-two years old, African American, male that presents in the clinic with complaints of right ear pain.

Biographic data—22 YOA, single, African American, English speaking, male, DOB 02/01/1995. He is currently employed as a car salesman. Mr. Brown is ill appearing, but seems reliable for the information provided. He seeks care today for right ear pain. He states, “It was throbbing pain that lasted all night, now it’s more of a dull ache.” Thyroid Gland and Tympanic Membrane Assessment Essay.

Severity—Using a pain scale of 1-10 with 10 being the worst pain ever the patient states “6”

Aggravating or relieving factors—The patient states, “heating pad helps.”

Timing—started last night 05/14/2017

Associated Factors—some difficulty hearing, patient is a non-smoker with no current medications

Patients perception—Mr. Brown states, “I couldn’t sleep at all last night.”

Past History—childhood history of asthma, appendicitis

Past hospitalizations/surgery—Appendectomy, Dr. Miller, South Georgia Medical Center 2012 was admitted for two days following for antibiotic therapy.

Immunizations—current

Medication reconciliation—Ibuprofen 400mg as needed for pain, social use of alcohol

Family history—significant for heart disease in father

SOAP NOTE: S=Constant right ear pain starting 05/14/2017, pain relieved somewhat by OTC NSAIDS and heat

O=Vital signs are as follows: temp 102, P-114, B/P-124/76, R-24, Nurse notes purulent drainage green in color from right ear, right ear tympanic membrane bulging and red. Patient rates pain a “6” on pain scale.

A= Acute Otitis Media

P=Rx Amoxicillin 500mg pot id for 5 days, Lortab 5 mg po q 6 hours prn pain

Follow up one week

The tympanic membrane can be viewed using an otoscope. Making a visual inspection of the tympanic membrane is an important piece of the health assessment. Jarvis, C. (2016) states, “The normal eardrum is shiny and translucent, with a pear gray color. The cone-shaped light reflex is prominent in the anterioinferior quadrant (at the 5 o’clock position in the right drum and the 7 o’clock position in the left drum). This is the reflection of your otoscope light. Sections of the malleus are visible through the translucent drum: the umbo, manubrium, and short process.” When inspecting the tympanic membrane there are a number of significant abnormal findings that indicate an issue with the ear. If the tympanic membrane is red in color and bulging on inspection this indicates acute otitis media. Acute otitis media is an infection of the middle ear. If left untreated the tympanic membrane becomes fiery red and bulging. Thyroid Gland and Tympanic Membrane Assessment Essay. The patient will experience earache, fever, and have transient hearing loss. A yellow/amber color of the tympanic membrane, with air bubbles viewed behind the membrane indicates otitis media with effusion. Otitis media with effusion symptoms may include a feeling of fullness in the ear, transient hearing loss, and a popping sound while swallowing. Retraction of the tympanic membrane, with prominent landmarks, the malleus shorter and more horizontal than usual, absent light reflection, and a dull appearance indicates an obstructed Eustachian tube and serous otitis media. Perforations of the tympanic membrane appear as around darkened area on the membrane. Perforations are the result of increasing pressure or trauma. Multiple perforations can lead to a scarred drum which appears as multiple white patches on the membrane. Multiple perforations can also be seen as a pearly white, or cheesy known as cholesteatoma which can lead to hearing loss. Fungal infections are seen as a colony of black or white dots on the membrane. A blue drum appearance indicates blood in the middle ear associated with trauma.

Inspection of the tympanic membrane using an otoscope is the preferred test used to screen patients with acute otitis media. Culture and sensitivity of any drainage associated may be done. Normal results for a culture would be negative for bacteria growth.

References

Boston: Butterworths; 1990 Clinical Methods: The History, Physical, and Labaratory Examinations. 3^rd edition.

Jarvis, C. (2016). Physical Examination and Health Assessment, 7th Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9781455728107/ Thyroid Gland and Tympanic Membrane Assessment Essay