Christina Master, MD: Hi I’m Dr. Christina Master. I’m one of the sports medicine physicians and one of the co-directors of the Minds Matter Concussion Program here at The Children’s Hospital of Philadelphia. We see a lot of concussions in children here at The Children’s Hospital and we’re sure that you do as well. We’d like to share with you a lot of the new information that we’re learning and update you on how to best diagnosis and identify concussions in children in your practice.

I’d like to introduce you to Ava. She’s one of our patients who’s had a couple of concussions from sports. She plays ice hockey. She’s completely recovered now, but she’s agreed to help us demonstrate the physical exam and the history that we would be taking to help you identify concussions in your practice.

All right Ava, so tell me about your last concussion.

Ava, Patient: It happened about a month ago.

Christina Master, MD: OK, tell me a little bit about how it happened.

Ava, Patient: I was going into a corner with a kid that who bigger than me and he hit me from behind.

Christina Master, MD: OK, and did you have symptoms right away?

Ava, Patient: No.

Christina Master, MD: OK, when did you start to have symptoms and start to wonder that maybe you had a concussion?

Ava, Patient: The next day.

Christina Master, MD: OK, and what were those symptoms?

Ava, Patient: I was feeling nausea. I had a headache and sensitivity to light.

Christina Master, MD: OK, and you were able to finish the game without any problems?

Ava, Patient: Yes.

Christina Master, MD: OK, did you go to school the next day?

Ava, Patient: Yes.

Christina Master, MD: OK, what happened at school?

Ava, Patient: I couldn’t focus, my head hurt.

Christina Master, MD: When did you start to think that you had a concussion?

Ava, Patient: That night.

Christina Master, MD: OK, and at that point did you seek care with anybody else?

Ava, Patient: My mom.

Christina Master, MD: OK, all right. And that’s when you decided to call and get an appointment to come in. All right, and were you continuing to do homework?

Ava, Patient: Yes.

Christina Master, MD: And how about spending time on your cell phone or a desktop computer?

Ava, Patient: Yes.

Christina Master, MD: And how did those make you feel?

Ava, Patient: They made my head hurt.

Christina Master, MD: OK, have you done any exercise since you had your injury?

Ava, Patient: No.

Christina Master, MD: OK, and then after resting for a bit at home, did that help you symptoms a little?

Ava, Patient: Yes.

Christina Master, MD: OK, in addition to the history of the current concussion, we’d also like to get some past information on her. We usually like to find out how she’s done in school prior to this. What were her grades before her injury? We also like to find out in her history, or in her family, does anybody have ADHD, dyslexia, or a learning disability. Because these are some factors that can sometimes complicate the recover.

In addition, we like to ask if there’s any history of migraines, anxiety or depression. In particular, we’re also realizing now that it’s important to find out if there’s any visual disturbance in the family. Whether or not she wears glasses, and is nearsighted or farsighted. Or if there’s any history in the family, or in Ava, of strabismus, amblyopia, eye surgery, or eye patching for any kind of lazy eye kind of phenomenon.

We also like to know if there’s any history of motion sickness because of vestibular system can often being effected after concussion. And a sign of motion sickness in the car may indicate they may have more of those symptoms after a concussion.

All right, so Ava I want you to take a look at my finger. Follow my finger with your eyes. Don’t move your head. We’ll start slowly and go faster. Let me know if it gives you any symptoms, otherwise if it doesn’t give you any symptoms, we’ll keep going, OK? All right. As you can see Ava is doing a great job following my finger. And as we go faster, she’s able to keep up. She doesn’t have any problems with any symptoms. She’s not blinking or having her eyes water excessively, or complaining of headache or dizziness.

Just to note, when you track sometimes you can have a few beat of a nystagmus at the end, gaze, like she has here, that’s normal. But when you come to the middle, she locks in nice and solid and there’s no nystagmus in the central gaze. This is the smooth pursuit portion of the exam.

Now Ava, I want you to hold your head still. I want you to look at my fingers left right, left right as fast as you can until it gives you symptoms or I tell you to stop, OK? Go ahead. Now as you can see Ava’s performing the horizontal saccades. She’s going nice and smoothly. It’s not fatiguing, it’s not tired. She’s not blinking or stopping because she’s having headache or dizziness.

Often times when kids are acutely symptomatic, they will have trouble with this movement. What happens is they’ll often have their eyes start to water, or they’ll blink, or they’ll stop and they say that they either have headache or dizziness provoked by this maneuver.

Let’s do it up and down now, Ava. Up and down, keep your head still, look at both of my fingers as fast as you can. So again, as you can see, Ava is not having any symptoms. She’s not having any watering of her eyes. Her eyes are not fatiguing. She’s not blinking or stopping because she has dizziness or headache. But often what we’ll do is also ask the kids. Did that cause any dizziness or headache, Ava?

Ava, Patient: No.

Christina Master, MD: Great, wonderful, all right. Take a look at my thumb. I want you to focus on my thumb. And then I want you to bounce, and keep bouncing and let me know when that starts to give you any headache or dizziness, or bother you at all. Otherwise, we’ll keep going and I’ll tell you when to stop. This is the vertical vestibulo-ocular reflex, or gaze stability testing. All right you can stop, Ava. That looks great. When kids have symptoms with this, they’ll often stop or they won’t be able to do it quite as rapidly. Often, they can have their eyes start to water, or they’ll complain of worsening headache or dizziness.

Now we’ll do the horizontal vestibulo-ocular reflex. Focus on my finger. Shake your head side to side, and keep going until I tell you to stop or if it gives you symptoms. Great, did that give you any symptoms at all, headache or dizziness?

Ava, Patient: Nope.

Christina Master, MD: Great, wonderful. So now we’re gonna measure some binocular vision function. In particular, we’re interest in convergence. And this ruler is called a convergence rule. You can purchase this, it’s a specialty piece of equipment used by developmental optometrist. If you don’t have access to a convergence rule, you can also us a pen, and have the patient bring it close to their face, and their nose, to estimate what they’re convergence is in the same manner.

We’re going to have her take a look at the letters on this card. We’re going to ask her when they become blurry and when the line becomes double. And that will give us a sense of where her convergence point is. Ava take a look at the letters on the card, are they clear?

Ava, Patient: Yep.

Christina Master, MD: Great, tell me when they get blurry.

Ava, Patient: Blurry.

Christina Master, MD: Tell me when they become double.

Ava, Patient: Double.

Christina Master, MD: Tell me when it’s single again.

Ava, Patient: Single.

Christina Master, MD: Tell me when it’s clear again.

Ava, Patient: Clear.

Christina Master, MD: Great, and then now we’re gonna measure her accommodation. Cover your left eye, this is single eye accommodation. Are those letters clear?

Ava, Patient: Yep.

Christina Master, MD: Tell me when they get blurry.

Ava, Patient: Blurry.

Christina Master, MD: And then cover your right eye. Are those letter clear?

Ava, Patient: Yes.

Christina Master, MD: Tell me when they’re blurry.

Ava, Patient: They’re blurry.

Christina Master, MD: Great, so we would record all of those numbers for convergence and accommodation and track that over time as she recovers. In general kids should be able to converge less than 6 cm, and we would expect that to be normal.

Lastly, we’ll take a look at your balance. We’re going to step out into the hallway. I’d like you to walk heel toe, heel toe like you’re on a tight rope. And we’ll do it forwards and backwards with your eyes open and closed. OK? All right great.

So now we’re gonna test her balance. We like to challenge their balance by having them do a tandem gait forwards and backwards with their eyes open and their eyes closed. Each step of the way gets a little bit more challenging, and is able to provoke more problems with kids who have concussion. And you’ll be able to identify them if they have balance difficulty.

Please note that kids with concussion, may have very poor balance. And so be aware that you’re near them, or nearby so that if they lose their balance, you can help steady them so that they stay safe.

All right Ava we’re going to walk in a tandem gait, heel toe, heel toe, eyes open going forward. And then I’ll tell you when to close your eyes. Go ahead. Great, so you can see she’s doing a great job. Now close your eyes. She has no sway. She’s keeping her hands by her side. Open your eyes and stop. Now we’re going to go backwards, eyes open. And this is a little bit more difficult than going forwards. And then closing your eyes is the most difficult part of all. Great, you can stop.

So a lot of our kids, when they have an acute concussion will have trouble with any of these maneuvers. Sometimes they’ll sway back and forth, sometimes they’ll have their arms go up from their sides to help them maintain their balance. And sometimes they’ll step off the tandem gait line because they’re not able to maintain their balance.

So that concludes the pediatric history and physical for the concussion. Thanks for joining us, and thanks to Ava for contributing and participating with us on this.

Rebecca Ichord, MD: Hello my name is Dr. Rebecca Ichord. I’m a neurologist at The Children’s Hospital of Philadelphia and director of the Pediatrics Stroke Program. Stroke in childhood is an important problem. Although it’s rare, when it happens, it’s a serious emergency and it’s important for the general public as well as health practitioners to understand the signs and symptoms.

In the case of a child having an acute stroke, their symptoms may be among the following: They may suddenly have difficulty understanding where they are, who’s around them. They may have sudden loss of their ability to speak or understand speech. They may suddenly lose the ability to see things on one side of their body. They may have sudden loss of strength or sensation involving the face, the arm and the hand or the leg. Or they may have sudden difficulty in balance and gait.

And if these symptoms should occur, the child should be considered to possibly be having a stroke. And the thing to do in that situation would be to have the child lie flat, do not give him anything to eat or drink, and call 911. And when the emergency responders arrive they should be told that the child’s having signs and symptoms of what could be a stroke. We call this a brain attack and it should be treated as an emergency.

Today we’re going to do a check-up of a young man who had a stroke sometime in the past. And he has kindly allowed us to check him out today so we can show some of the signs and symptoms that we might see on an examination. Are you ready? All right, tell me your name.

Rebecca Ichord, MD: And so I’m checking to see if he’s aware of himself and his surroundings. And who’s that lady over there?

Patient: My grandma

Rebecca Ichord, MD: OK, and so you know where you are?

Patient: CHOP

Rebecca Ichord, MD: That’s right. And what year is it?

Patient: 2015

Rebecca Ichord, MD: OK, so we figured out that you know who you are, who’s around you, where you are and the date. And this is what we call orientation. A child who is having an acute stroke may have some confusion and be unable to describe where he is or who is around him.

Now I’m going to ask you to do some little tests that have to do with your speech. And testing speech is a very critical part of evaluating for signs and symptoms of a stroke. Some children may only have a loss of their speech as the sign of their stroke. And so I’m going to ask you to do a few things.

Let’s do, let’s see if you can repeat what I say. Little children like to play outdoors.

Patient: Little children like to play outdoors.

Rebecca Ichord, MD: Excellent, so I’m listening to hear how well he can formulate the words, how well he can make the sounds clear. Now I’m going to ask you to remember some words that I’m going to ask you to say. We call this recall. And I’ll ask you now, and then I’ll ask you again a little bit later. And that’s called delayed recall. Children who have an acute stroke may have trouble with recalling, or remembering words that they had just heard. You ready? Red, pencil, bridge. Go ahead and tell me.

Patient: Red, pencil, bridge

Rebecca Ichord, MD: 100%, I’ll ask you again in a few minutes. Now I’m going to ask you to name some things. So naming is another aspect of speech. And some children have difficulty with naming objects. So here we go. See these pictures, these are very simple, easy pictures. I want you to say the name of each thing. You ready? And what do you call that?

Patient: Clock, T-shirt, pencil, baseball, skateboard and bike

Rebecca Ichord, MD: Excellent, so he got them all correct. And in addition I could understand the words very clearly. In a child who’s having a stroke that affects speech, they have trouble getting the word out, or they may say the wrong word, or they may not be able to say the word at all. So your naming is great.

All right, let’s move on to some other things. Now I’m going to look at your vision. I want you to look at my nose right here. And first of all I notice that when you look at me, your eyes are looking straight ahead. And if I move your eyes follow me. So that tells me that you’re able to see things well enough to have your eyes look where they need to look. And children who have a sudden loss of vision on one side, their eyes may prefer to stay looking in one direction. So it’s very good, it’s very normal that your eyes are looking straight at me.

And now I’m going to test each eye by itself. And this is a way that we can tell if the vision problem is involving both eyes or just one, or it’s in the brain. Looking right here at my nose I’m going to cover your eye. And keep looking straight at my nose. Now what this is is called testing visual fields. And it’s simply showing a number and you tell me how many fingers you see. Ready, how many?

Patient: One, two

Rebecca Ichord, MD: How many?

Patient: Two, one

Rebecca Ichord, MD: Good, so I’m showing a finger in each field and to see if he can check them. And he got them all right. Ready, here we go with the other eye.

Patient: Two, four, one, two

Rebecca Ichord, MD: OK, so in the case of a child having a stroke, if I cover one eye and if I show him numbers over here and he gets these correctly, then I know this visual field is normal. If I show them over here, for example, and he can’t see them clearly on this side, that would mean that he has what we call visual field loss. And that’s a typical kind of abnormality in an acute stroke that helps us neurologists to figure out where the problem might be.

Very good, OK, now let’s see how your eyes are moving. Can you look at my thumb? And watch where it goes. Very good, and so his eyes are able to follow in all directions. And in some children who have certain areas of the brain that control eye movements, where there is a stroke in that location, they may not be able to move their eyes in all directions. But you did 100%.

OK, let’s look at your face. Can you give me that big smile again, excellent. And so we notice that his face is very strong, that his smile is very strong on both sides. And in the case of a child who has an acute stroke, the one side of the smile might be not present and be very weak. All right, let’s have you close your eyes really, really tight. And you can see that he’s able to squeeze his eyes tight on both sides. In a child who’s having an acute stroke with weakness of the face, they may not be able to close the weak side of the face, that eye very tightly. That’s good you can open your eyes. Your eyes, your face is very strong.

And now just again look straight at me, I’m going to check the sensations. So I want you to tell me if the two sides feel the same or different.

Patient: Same

Rebecca Ichord, MD: Same?

Patient: Same, same

Rebecca Ichord, MD: And let’s go on down to your arms. Same or different?

Patient: Same

Rebecca Ichord, MD: Same or different?

Patient: Same

Rebecca Ichord, MD: Same or different?

Patient: Same

Rebecca Ichord, MD: And again, in the case of a child who might have a stroke that affects sensations on one side, they may tell me that on one side of their body or one side or their face, it doesn’t feel the same as the other side. I’m going to check your ability to hear. Ready? OK, I want you to point to where you hear the sound.

Good, very good. So again, in a child how might have loss in their hearing you would expect to see possibly some loss in being able to detect hearing that little soft brush of the fingers on one side.

OK, let’s move on down, we’re doing great here. Can you show how you shrug your shoulders? All right, and what we notice is that his shoulder is a little weak on that side, he can’t raise it quite as much. Although he is trying really hard. OK, that’s good. So there’s weakness on that side. And then let’s look at your arms, can you hold your arms up like this for me? How about keeping them straight in front? And I’m going to let go. Keep your arms in front of you like that, and then try to turn your arm over like this. And so you can see this side moves very well, but this side he can’t move quit so well. And that’s because there’s weakness on this side of the body.

And again, in the case of a stroke, a child may be unable to lift that arm, or open their hands. Let’s see both of these hands, can you make that hand spread open? Beautiful, and make it a little “O” like that. And make your hands tap like that. And that’s good, that’s what we like to see. And the weak side, he can’t really make the hands open. Let’s see what you can do. I know you’re willing it, and it just won’t open. And how about if you try to make that “O”. Can’t quite do it. And can you tap it at all, no?

So he’s lost the fine dexterity and the strength that it takes to control that hand in a normal way. And so that’s what we might see in a child who has a stroke that affects strength on one side of their body. And it tends to especially involve the face and the arm and the hand. And then we see that combination, then that’s a situation where we especially would worry about a stroke being, going on in that child.

So let’s see onto your legs now, right. So let’s see, can you lift this knee up in the air like this? Good, keep it there really strong. And I’m pushing, pushing, and I can’t push it at all. So that’s very strong. How about this one? And you’re having to work just a little harder to make that strong. Let’s make your legs straight now. Keep it there nice and strong. And I’m gonna try and bend it. And I’m not able to bend it because it’s too strong. OK, how about this one?

So right away we can notice that this leg, he can’t quite get it all the way straight. And if I try to push it down, I’m able to push it down a little bit. And so that’s again, sign of weakness. And so what we see is weakness of the shoulder, the arm, the hand and the leg. And that’s the typical distribution, the typical location of loss of strength involving someone who has a stroke.

That’s right, OK, now let’s check your walking, you ready? There we go, can you stand over here? That’s it. And what you may notice is that because the left leg is a little bit weak, he can’t really keep it straight. And also the left arm is a little weak so it tends to kind of hang here a little bit more than the right side.

Now let’s see how you can walk. And so he can’t really push off quiet as strong with that left side. And come on back this way. And that left side just can’t make it, can’t make it as strong and straight as the right side. All right, very good, you can sit up here. Very good. And you can see, he’s figured out how to get around even though he’s weak on that left side. But even though he’s figured it out, he still has a little trouble and has to compensate for the weakness in that left side.

Alright, do you remember those three words? What were they?

Patient: Red, pencil and bridge

Rebecca Ichord, MD: Excellent, so his recall is very good. All right, I think we're done.

Andrew Bauer, MD: I'm Dr. Andrew Bauer, the medical director of the Thyroid Center of The Children's Hospital of Philadelphia. The Children's Hospital Thyroid Center is one of the busiest Thyroid Centers in the United States and we see the full range of thyroid diseases within pediatrics from newborns up until age 23; to include congenital hypothyroidism, acquired hypothyroidism, hyperthyroidism we see about 50 new Graves patients per year, thyroid nodules and thyroid cancer and thyroid cancer syndromes. 

So this video is an educational video to try to highlight what a normal thyroid exam should be and to highlight what some of the abnormal findings are in an exam that we hope will raise awareness for the importance in what to look for in physical exams for pediatric thyroid disease.

So we're gonna start today. Lauren was kind enough to be our model for what a normal thyroid exam is so the first thing we do for the exam is just have a patient hopefully sit comfortably on the table and their shoulders back and just in a chin neutral position.

So in that position the thyroid gland sits just above the collarbone in the middle portion of the neck and the neck is divided into various levels. The American Thyroid Association in 2009 published a consensus on that and the middle part of the neck is designated as level VI. So if we just go through the levels of the neck (which there is a diagram that's going to be in the video), level I is under the chin, IIA and IIB are going along the mandible — the angle of the jaw and IIb is back here and coming down the strap muscles (the sternocleidomastoid) IIB's up here, level III is here, level IV is here.

Level V is the posterior triangle which the posterior surface or margin of sternocleidomastoid is the front part of the level V and then as that back triangle back here which is level V. Level VII is down here so again just to go quickly through it — I, IIA, IIB, III, IV, V is back here, VI is the middle part of the neck where the thyroid is and VII is just that sternal notch.

So the thyroid gland sits above the collar bone and it has an H or butterfly shape which we cannot see in Lauren because she has a normal thyroid exam.

The next part of the exam, we'll just have Lauren look up at the ceiling and when she looks up this is now neck extension and again you should not be able to see the outline of the thyroid lobe or the thyroid gland which we cannot see which again says that it's a normal exam by inspection. While we're in this position we also look for neck symmetry. So we're looking for lymph nodes that might be enlarged on one side compared to the other so what we can see from Lauren's exam again if we look along the lateral neck, even on both sides, there's no fullness when we look along the medial aspect of the sternocleidomastoid or in the middle part of the neck so a completely normal exam by inspection.

The next part of the exam is to have Lauren drink some water and we can watch her swallow and we can see if we can see the outline while she's swallowing. So take a sip and then look up and swallow at the same time. And we can see motion in the neck but you cannot see the thyroid gland and again that's another reassuring part of the exam that says that it's normal. Okay, we can do it one more time and again all you see is motion but you don't actually see the thyroid gland itself moving up and down because it's not enlarged.

So the thyroid gland is not visible, there are no lymph nodes that are visible and the width of her neck is symmetric both on the left side and on the right side.

So now starting with the physical exam portion, we find the cricothyroid membrane and then right below it is the isthmus which is the piece of tissue that connects the left side to the right side. So I find that and then I just use my fingers and gently roll the thyroid lobe under my fingers and try to feel if there's any fullness — if there's something that would feel like a nodule and what the texture of the tissue itself is. So here's a superior aspect. Lauren's gland is easy to feel, it's soft, there are no nodules and I found the anterior aspect and again feel the entire left lobe which feels normal both in texture and there's no evidence in nodules.

So while I'm over here on the left side, I'll complete the lymph node exam as well so I usually start while my hands are in the lower portion of the neck the medial aspect of the sternocleidomastoid and just rub along the anterior aspect, along where the carotid is coming up and just feeling for any lymph nodes or masses which I do not feel.

Going up in Level III and heading up into IIB and then once up in IIB the I just go along the belly of the sternocleidomastoid back down and no lymph nodes behind the muscle itself and then find the inferior — I mean the posterior aspect and no lymph nodes that are hiding back there as well.

And then into level V — look down just a little bit Lauren — sometimes level V you have to have them come out of neck extension a little bit so you can get a full exam. Good, now I'm gonna switch sides.

Again, get myself reoriented so Lauren if you can look up. Come down and find the cricothyroid membrane and then find the isthmus just right here and gently let the thyroid lobe roll under your fingers as you move out laterally along the superior aspect, along the belly of the lobe, on the inferior aspect and similar to the left lobe, the right lobe feels normal. Easy to feel, no nodules, normal texture on exam.

Then doing the lateral lymph node exam, starting in level IV of the medial aspect of the sternocleidomastoid, no lymph nodes. Level III and then coming up into the IIA, IIB region then along the belly of the sternocleidomastoid coming back down and then the inferior aspect of the sternocleidomastoid coming back up and then look down again a little bit Lauren, there you go and into level V and no lymph nodes back there.

And if you find something that's abnormal in one side which I do not find in Lauren, then you can always check on the other side. So often times, especially in pediatrics we'll feel lymph nodes under the angle of the jaw which is a common place to find them but if you feel one — some on one side then you should also feel to see if there's symmetry in the other. But nothing on Lauren's exam and this is a normal thyroid exam. Cannot see the thyroid, can feel it by palpation, symmetric neck exam, no abnormal lymph nodes. Thank you.

So today we're gonna do an exam on Jennifer. We've already performed an ultrasound and Jennifer has already had a fine needle aspiration biopsy which we know is positive for papillary thyroid cancer so we're gonna go through the exam today to try to highlight some of the areas on Jennifer's exam that we want people to be aware of. One particular, important part for Jennifer's exam is that she does not have a distinct nodule. Her thyroid gland is not visibly enlarged but she presented with lateral swollen glands which are a common finding in pediatrics. Most of the time it's infection but part of the differential diagnosis is papillary thyroid cancer so we're trying to highlight Jennifer's exam to raise awareness that when people feel swollen glands they need to think about the thyroid gland and potentially thyroid cancer and not just a potential — for infection which is definitely more common but this in an important part for people to be aware of.

All right, good morning. So we're gonna start by repeating our thyroid exam today. So the first part that we're gonna do is just the inspection part of the exam so you're in a perfect position sitting up straight on the table and looking forward with your chin in a neutral position and from this area we can't see any specific enlargement of the thyroid which sits in the middle part of the neck but we can see some asymmetry that the right side of Jennifer's neck is not as full as the left side so this is more full, pushing out more towards the side of her shoulder.

So the next part of the exam is to have Jennifer look up at the ceiling just with neck extension. So level VI is the hyoid bone down to the sternal notch which is level VII down here and then the medial aspects of the sternocleidomastoid and in the lower part of level VI is where the thyroid gland sits.

Now on Jennifer's exam we cannot see the outline of the thyroid gland and if we ask Jennifer to take a drink of water, if you could do that — and then get back in that neutral position and swallow — you can see the thyroid gland here — move up again — can you do it one more time Jennifer?  So right here, you can see that movement, very slight movement going up but again not a distinct outline of the thyroid gland which has that H symbol to it.

So again kind of emphasizing that on exam, the thyroid is not very large compared to some of our other patients but again the next part of the exam we'll feel on inspection to see if there's something else going on in the thyroid that might explain the fullness on the left side of the neck.

We'll start the exam, I'm going to switch sides and start here (you can put your water down if you'd like) and look up again. For that portion I start in the middle — I find the cricothyroid membrane and then find the upper portion of the isthmus and then I start marching along — along this would be the right side so the right thyroid lobe and I notice a little fullness right here that feels like potential lymph node above the right thyroid lobe and then along the belly of the right thyroid lobe which feels fine. Feels like a normal thyroid lobe on this side and then the posterior aspect — or inferior aspect of the right thyroid lobe.

So the right side looks fine. The tissue itself feels normal except there's one little area right above the right thyroid lobe right here which is hard to see but I can feel under my fingertip. Then I'd go up the lateral neck — so lateral neck is level IV, level III, IIB and IIA. So I'd start with the medial aspect of the sternocleidomastoid feeling for lymph nodes which I do not feel so far, down the muscle belly coming back down and then along the posterior aspect of the strap muscle and no lymph nodes on the right side.

Can we move your head a little bit more that way? Good and then the posterior triangle, this is level V back here and uncommon place to find lymph nodes but an important part of the exam and no lymph nodes back here. Good.

So I'm going to switch sides and again start in the middle, find the cricothyroid membrane and then find the isthmus and start to feel along the left lobe and when I'm feeling on the left side which is again hard to see it's just more fullness. There's just a lot of fullness on the left side. Not a distinct nodule but fullness and then the belly of the left thyroid lobe and the inferior aspect of the left thyroid lobe which seems to extend a little bit lower and just has some fullness.

Then going up the lateral neck there's an area right here which is actually kind of similar to the other side. That again feels like a lymph node that's just above the left thyroid lobe and then going up the lateral neck starting in level IV along the medial aspect of the sternocleidomastoid, level III and then up here is where we start to see that full — feel that fullness that we can see and once I start to feel something that seems a little bit different on one side than the other then I kind of put my fingers in the opposite sides of the neck to see if its symmetric.

On Jennifer's exam, there's some — there are a few lymph nodes up here which I do not feel on this side and then the largest area is just this area right — kinda level IIB behind the strap muscle, behind the sternocleidomastoid so fullness. And then come down the belly of the muscle in the inferior aspect and then again in level IV and nothing in VA or VB. So fullness to the left lobe. Fullness to the left lateral neck, especially up in level IIB and then two little lymph nodes above the isthmus in the middle —  one on the left and one on the right. All right and that's it.

Dr. Bauer: Good morning.

Amanda: Good morning

Dr. Bauer: How are you?

Amanda: I'm good, how are you?

Dr. Bauer: All right. This morning we're gonna take advantage of Amanda having a nodule in her right thyroid lobe and try to highlight what a nodule looks like on exam and then kind of go through the exam to see what I'm looking for. Some of this is already taken care of on ultrasound but the physical exam's the first step and the most important. So Amanda noticed her nodule in June of last year and what you can see when her chin is in neutral position is just some fullness in the right side cause that's where the nodule is — it's in the right lobe. And then if Amanda goes to full neck extension that's when you get a little bit more sense that there's some fullness that's here in this area than it is in the left side.

And now if you have enough saliva, we can swallow — you can swallow and you can see the nodule move up and down and that's the first part of the exam — just looking, having the patient swallow and watching the thyroid move to look for symmetry.

So now I'm going to do the physical exam. We're going to start with the thyroid cartilage, the membrane and then come down and find the isthmus of the thyroid — the upper part of it and then I usually start on the normal side which in Amanda's case is going to be on the left side so I'm just gonna gently roll my fingers over her left thyroid lobe to try to get a sense of what the tissue feels like. Is it enlarged or smaller? Is there a nodule or no nodule? And in this case there is only a nodule on the right lobe.

So part of that is well as the lymph node exam. So if we go from levels IV, III and II we're just moving up the medial part of the sternocleidomastoid and now from level III into level II and there's no lymph nodes on the left side and then along the muscle belly down again from II to III to IV and the posterior aspect of the sternocleidomastoid as well.

And that's the side that's unaffected and level V is back here. And also no abnormal lymph nodes are noted on the left side.

Now onto the right side just gently roll your fingers over the nodule. See what it feels like — in this case it's smooth, kind of rubbery and then there's only one that I can feel on exam and then again feeling for lymph nodes so we're now in level IV, III and II up here and again just gently roll your fingers over the medial aspect of the sternocleidomastoid and no lymph nodes.

Then along the muscle belly and along the posterior aspect and usually the patient's in a sitting position on a table but feeling back here again in level V and no abnormal lymph nodes so it’s just that right side — a thyroid nodule. No abnormalities on the left side, no abnormalities as far as lymph nodes are concerned. Thank you.

Amanda: Thank you.

Dr. Bauer: Good morning Chloe.

Chloe: Good morning.

Dr. Bauer: So this morning we're gonna briefly go over a thyroid exam on a patient who has autoimmune hyperthyroidism. Otherwise known as Graves' disease so Chloe's been kind enough to agree to do that. So for some of our patients when you walk into the room you can see that they're hyperthyroid but Chloe is currently on medicine so her hyperthyroidism is relatively well controlled. But the things that you would see is someone who is restless, fidgety, they can't sit still on the table and then often times you'll notice, which you can see in Chloe is that her thyroid is enlarged.

So without even moving her neck or her chin, you can already see the outline of Chloe's thyroid. Her gland is at least four times enlarged. Probably five to six times enlarged. So even in a chin neutral position you can see Chloe's thyroid gland. It's even — the left side and the right side are even and so if we have you look up at the ceiling, then you can start to see this real large thyroid gland even pushing the strap muscles out to the side so not a subtle exam for hyperthyroidism. This is kind of one of the larger glands that we typically see.

The other things we can ask our patients with hyperthyroidism is to look at their signs and symptoms. So Chloe still has a little bit of a tremor so if you ask the patient to lift — just to extend their arms straight out you can see that there's a little tremor. Sometimes it's even on both sides and you don't have to keep going. But Chloe's is a little bit more on the left than the right. You can ask them if they are having problems falling asleep or if they are a little more fatigued than usual. Often times they have an increased appetite but they're losing weight. I don't know if you're weight is still — and those things sometimes get better and sometimes don't with medical therapy. So Chloe's been on medicine for how long?

Chloe: I think — I'm not sure. I've been on methimazole.

Dr. Bauer: Right, methimazole the anti-thyroid medicine and we've decided now to do permanent or definitive therapy by surgically removing Chloe's thyroid gland for the trade-off of permanent hyperthyroidism.

So for the thyroid exam, what I'm gonna do is first start with just as I said looking. So you can look and see that the thyroid gland is enlarged and see what the person looks like. Otherwise seemingly relatively calm and collected besides the tremor and then we're gonna listen.

So the first part is listening to see if you can hear the blood flow through the thyroid gland which is called the bruit. So you can — for Chloe's exam you can hear the blood flowing through which is almost like a murmur like sound. A little bit more on the right than on the left and sometimes you can accentuate by having the person take in a deep breath and hold it. So can you take in a deep breath and hold it and then you can let it out and when Chloe did that the pitch went up and you could hear the bruit a little bit more prominently. And one more time on the left side and you can let it out. Good.

So that's really the only exam that we think about for hyperthyroidism. Listening for blood flow.

The next part of the exam is similar to the other exams and it starts with just the inspection which we've already done so if we just look, there's the thyroid cartilage and then the cricothyroid membrane and the cricoid cartilage and right below it is the isthmus and so the isthmus starts up here and you almost can't even feel the bottom of it — it's way down here so if you looked up a little bit I might be able to get my finger under there but it's -- as you can see very enlarged. Alright look back down, chin neutral position. Actually if you can — can you look up a little bit? Is your mouth moist enough that you can swallow?  So that's good for this morning.

So again I'm gonna find the cricothyroid membrane, the top of the isthmus, and then just gently run your fingers along the lobe. This is the left lobe, trying to feel if there's any nodules so any lumps that are more prominent as you do that and for a hyperthyroid exam the tissue is usually kind of rubbery — soft to rubbery in sensation in contrast to thyroid cancer where the tissue often times is hard. So this is a very rubbery gland. That's the left side. For the right side, I'll just have to switch sides and again so when I'm pushing any pain or discomfort?

Chloe: I can feel some pain to more on the left side I think so yeah.

Dr. Bauer: So again, just feeling along the whole surface of the thyroid gland and Chloe has a very symmetric gland. Rubbery, no nodules. For hyperthyroidism you still feel for lymph nodes because it is possible to have lymph nodes associated with autoimmune thyroid disease. For Chloe's gland being so large it's a little more difficult to feel but if you start up in kind of the IIa, IIb region and then again just let the tissue roll under your fingers and try to move down you can't get too much and I won't push too hard to feel lymph nodes but I don't feel any prominent lymph nodes.

Very rarely we have patients that have both hyperthyroidism and thyroid cancer. So the lymph node exam is always a part of the thyroid exam when you find an abnormality in the thyroid gland. You have one little lymph node there but not concerning feeling and then here IIb going into III, level IV up the strap muscle the sternocleidomastoid and then back into Level 5 and no lymphadenopathy. Excellent. And that's it so, do you have any questions?

Chloe:  Yeah, will I have ice cream after my surgery?

Dr. Bauer: I think we can arrange for ice cream after the surgery. Great, thanks for cooperating.