Thyroid + neck exam

Question 1

How is the thyroid located?

Answer 1

• butterfly shaped gland that covers the 2nd and 4rd tracheal rings
• palpate inferiorly from the midline of the chin until you feel a hard structure = thyroid notch
• inferior to this you can feel a dip (cricothyroid ligament) and then another hard structure (cricoid cartilage)
• below the cricoid are the 1st and 2nd laryngeal rings
• the normal thyroid is palpable in around 50% of females and 25% of males
• 50% of the population have an additional pyramidal lobe it the middle

Question 2

Upon general inspection of the patient in a thyroid exam, what are you looking for?

Answer 2

1. Body type:
   - hyperthyroid: weight loss, muscle
   - hypothyroid: weight gain
2. How they are dressed:
   - hyperthyroid: heat intolerant, underdressed
   - hypothyroid: cold intolerant, overdressed
3. How they are acting:
   - hyperthyroid: anxious, restless
   - hypothyroid: fatigue
4. also the standard are they comfortable/well at rest, any medication, anything of note etc etc

Question 3

Upon inspection of the neck in a thyroid exam, what are you looking for?

Answer 3

1. inspect the front + both sides - look at the contour of the neck
2. look in the mouth (lingual thyroid)
3. scars or any asymmetry?
4. any obvious swelling? (goitre)
5. ask patient to take a sip of water and swallow - does the thyroid move upwards on swallowing?
   - if any identifiable swellings also move up, they are likely associated with the thyroid

Question 4

How should you palpate the neck + thyroid?

Answer 4

• tell the patient what you are doing before you stand behind them
• ask them to relax their neck
• palpate with both fingertips one the lobes of the thyroid
• note any swellings, repeat the swallowing test and not any thrills (vibration from increased blood flow in thyrotoxicosis)
• if there is a midline mass, ask the patient to stick their tongue out –> a thyroglossal cyst will move
• is the trachea central?
• any lymphadenopathy?

Question 5

If a lump is found, in what terms should it be described?

Answer 5

1. size - measure
2. shape
3. surface - smooth/rough
4. colour
5. contours - regular/irregular. Plane of attachment
6. consistency - firm, soft, fluctuant, rubbery, lobulated?
7. temperature
8. tenderness
9. trans-illumination - if you shine a pen torch into the lump, what happens?

Question 6

Compare how the hands would appear in a patient with hyper and hypothyroidism?

Answer 6

Hyperthyroid:

1. Acropachy - similar to clubbing but affects the whole finger (Specific to Grave’s)
2. Fine tremor
3. Sweaty palms
4. Pulse - tachycardic and irregular

Hypothyroidism:

1. Dry hands
2. Pulse - bradycardic and irregular

Question 7

Compare how the face would appear in a patient with hyper and hypothyroidism?

Answer 7

Hyperthyroidism:

1. Exophthalmos - anterior displacement of the eyes (specific to Grave’s disease)
2. Lid lag - upper eyelid is more displaced than normal due to proptosis

Hypothyroidism:

1. Coarsened facial features
2. Dry hair
3. Thinning of eyebrows
4. Facial myxoedema (severe hypothyroidism - cutaneous oedema)

Question 8

Compare how the upper + lower limbs would appear in a patient with hyper and hypothyroidism?

Answer 8

Hyperthyroidism:

1. proximal myopathy - difficulty stand from chair, weakened flexion/extension against resistance
2. brisk reflexes
3. pretibial myxoedema (specific to Grave’s disease)

Hypothyroidism:
1. slowly relaxing reflexes

Question 9

How does the chest appear in a patient with hypothyroidism?

Answer 9

1. pleural effusion - dullness to percussion, absent breath sounds
2. pericardial effusion - signs of tamponade if severe, e.g. raised JVP, distended neck veins