As part of the introduction, what 6 things should you do?
- Wash hands
- Introduce yourself
- Confirm pt details (name / DOB)
- Explain the examination
- Gain consent
- Position the patient
How should you position the patient for a thyroid examination?
Sitting on a chair
What equipment will you need to assess thyroid status?
Stethoscope
Glass of water
Tendon hammer
Piece of paper
On inspection, what is the patient’s behaviour like?
Hyperactive? Agitated? Anxious? Fidgety? All indicate hyperthyroidism
On inspecting the patient’s hands, what 4 things should you look for?
Dry skin (hypothyroid)
Increased sweating (hyperthyroid)
Thyroid acropachy - phalangeal bone overgrowth (Graves’ disease)
Palmar erythema - reddening of the palms at the thenar / hypothenar eminences (hyperthyroidism)
How would you assess ‘peripheral tremor’?
What is peripheral tremor suggestive of?
- Ask pt to place their arms straight out in front of them.
- Place a piece of paper across the backs of their hands.
- Observe for a tremor (paper will quiver).
Peripheral tremor can be a sign of hyperthyroidism.
When assessing the pulse, what should you look for?
Assess the radial pulse for:
1) Rate
Tachycardia (hyperthyroidism)
Bradycardia (hypothyroidism)
2) Rhythm
Irregular (Atrial fibrillation) -> Thyrotoxicosis
What 3 features should you inspect the face for?
Dry skin (hypothyroidism)
Sweating (hyperthyroidism)
Eyebrows - loss of the outer third (hypothyroidism) [rare]
What should you look for in the eyes?
Exophthalmos (anterior displacement of the eye out of the orbit)
How should you assess the eyes for exophthalmos?
Inspect from the front, side & above.
Note if the sclera is visible above the iris (lid retraction) - seen in Graves’ disease
Inspect for any redness / inflammation of the conjunctiva.
What is bilateral exophthalmos associated with?
Graves’ disease
Caused by abnormal connective tissue deposition in the orbit & extra-ocular muscles.
How would you assess eye movements in a suspected thyroid patient?
- Ask pt to keep their head still & follow your finger with their eyes.
- Move your finger through the various axes of eye movement (“H” shape).
- Observe for restriction of eye movements & ask pt to report any double vision or pain.
What does restricted eye movements indicate in this context?
Graves’ disease
Due to abnormal connective tissue deposition in the orbit & extra-ocular muscles.
How would you assess for ‘lid lag’?
- Hold your finger high & ask the patient to follow it with their eyes, whilst keeping their head still.
- Move your finger downwards.
- Observe the upper eyelids as the patient follows your finger downwards.
How would you identify that ‘lid lag’ is positive?
The upper eyelids will be observed lagging behind the eyes’ downward movement (the sclera will be visible above the iris).
Lid lag occurs as a result of the anterior protrusion of the eye from the orbit (exophthalmos) which is associated with Graves’ disease.
On examination of the neck, what should you look for?
Inspect the midline of the neck (in the region of the thyroid).
- Any skin changes? eg. Erythema
- Any scars? eg. previous thyroidectomy
- Masses: note any swellings / masses in the area - assess size & shape.
The normal thyroid gland should not be visible.
If a mass is noted on inspection, what should you do?
- Ask pt to swallow some water.
- Observe the mvt of the mass
- Masses embedded in the thyroid gland will move with swallowing
- Thyroglossal cysts will also move with swallowing
- Lymph nodes will move very little - Ask pt to protrude their tongue
- thyroid gland masses / lymph nodes will not move
- thyroglossal cysts will move upwards noticeably
Before palpating the thyroid gland, what should you do?
Stand behind the patient & ask them to slightly flex their neck (to relax the SCMs).
Place your hands either side of the neck.
Ask if the patient has any pain in the neck.
Describe the 8 steps involved in palpation of the thyroid gland.
- Place the three middle fingers of each hand along the midline of the neck below the chin
- Locate the upper edge of the thyroid cartilage (“Adam’s apple”)
- Move inferiorly until you reach the cricoid cartilage / ring
- The first two rings of the trachea are located below the cricoid cartilage and the thyroid isthmus overlies this area
- Palpate the thyroid isthmus using the pads of your fingers
- Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus
- Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass)
- Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it will rise during tongue protrusion)
When palpating the thyroid gland, what 5 things should you be assessing?
Size - does it feel enlarged? (Goitre)
Symmetry - is one lobe significantly larger than the other?
Consistency - does the thyroid feel smooth or nodular? (?multi-nodular goitre)
Masses - are there any distinct masses within the thyroid gland’s tissue?
Palpable thrill - sometimes noted it thyrotoxicosis - due to increased vascularity.
If a thyroid mass is noted, what should you assess?
Position Shape Tenderness Consistency Mobility
Which lymph nodes should you palpate to identify local lymphadenopathy?
- Supraclavicular nodes
- Anterior cervical chain
- Posterior cervical chain
- Submental nodees
Local lymphadenopathy may suggest metastatic spread of a primary thyroid malignancy.
What is the significance of the position of the trachea in this context?
Any deviation of the trachea may be caused by a large thyroid mass.
In the context of a thyroid examination, where would you percuss & what would this indicate?
Percuss downwards from the sternal notch.
Retrosternal dullness may indicate a large thyroid mass, extending posterior to the manubrium.
