The Curbsiders' 'Hot Takes'

Have I Been Doing This Exam Wrong All This Time?

Matthew F. Watto, MD; Paul N. Williams, MD


August 24, 2020

This transcript has been edited for clarity.

Matthew F. Watto, MD: We are back. This is the Curbsiders. I'm Dr Matthew Watto, here with my good friend, Dr Paul Nelson Williams. Can you tell everyone what we are doing in this video?

Paul N. Williams, MD: We are recapping one of our podcast episodes. The particular episode that we refer to in this video is pearls and practice points about hypothyroidism that we learned from Dr Susan Mandel.

Watto: This episode was jam-packed. It was hard to pick two or three pearls that were my favorites from this one. Paul, I will let you go first. Tell the audience something great.

Williams: I learned that I may have been doing the physical examination wrong this entire time. The way Dr Mandel approaches the thyroid exam is different from what a lot of people were classically taught. In classic teaching, you approach the patient from behind and use your fingertips to feel. Instead, she approaches the patient from the front and uses her thumbs at the thyroid isthmus. When she finds that, she describes it as a stretched-out gummy worm. Then you can move laterally against the trachea, find out where the body of the thyroid is, and palpate for nodules that way, which is completely different from what I've been doing and very practice-changing for me.

Watto: I totally agree. I was definitely going to get arrested one day for coming up behind somebody.

Williams: Just on the subway, screening for thyroid nodules.

All of her points were solid gold, but the discussion I particularly enjoyed was when to start checking. This idea of screening asymptomatic patients — there's not a whole lot of utility to that, and in fact, it's not recommended. The symptoms of hypothyroidism are so protean because thyroid physiology affects virtually every organ system. Her point is that you should have a case-finding approach. There is a low suspicion to check a patient for thyroid disease. One of the pearls she talked about was related to testing, which you thought was practice-changing.

Watto: She was talking about biotin and how it cross-reacts with both the TSH assay and the tests for T3 and T4. It looks like someone has a very low TSH but a high T3 and T4. She's actually seen, or there have been case reports of, patients getting treated for Graves disease, when actually they just needed to hold their biotin for at least 24 hours before testing. She actually recommends that patients hold it for 2-3 days before testing because the biotin vitamins for hair or nails have 5000-10,000 µg of biotin and the daily recommended dose is 75 µg.

The other important pearl — and this is certainly expert opinion, but in her experience — once you normalize a patient's TSH, it takes a good 2-3 months before their symptoms of hypothyroidism go away and they feel well again. That would be great counseling, to tell the patient, "Look, even after we get your numbers looking good, it might be another 2 or 3 months until you feel well again."

That is just a little taste of what is a jam-packed episode. If you want to hear the rest, you can click on the link below. Until next time, this is Dr Matthew Frank Watto.

Williams: And I remain Dr Paul Williams. Thank you and goodbye.

Click to hear the full episode, Hypothyroidism Master Class with Susan Mandel, MD, MPH, or find the Curbsiders podcasts on iTunes.

The Curbsiders is a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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