Share your insights

Help us by sharing what content you've recieved in your exams


Thyroid examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patientโ€™s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Sit patient in the middle of the room (so you can stand behind them)
  • Expose patientโ€™s neck

General inspection

  • Patient: well/unwell, anxious/nervous, hot/cold, facial complexion (myxoedematous, flushed), obvious muscle wasting, BMI, obvious thyroid swellings, dry hair/waxy skin
  • Around bed: excess clothes

Hands

  • Fine tremor: ask patient to stretch out arms and hands with fingers straight and separated. A tremor is more easily visualised with a sheet of paper resting on top of the patientโ€™s hands (fine tremor = thyrotoxicosis).
  • Nails: thyroid acropachy (Gravesโ€™ disease), onycholysis (thyrotoxicosis)
  • Palms: cold and dry (hypothyroidism), moist and sweaty (thyrotoxicosis), palmar erythema (thyrotoxicosis)
  • Pulse (tachycardia and AF in thyrotoxicosis)

Face

  • Generally: waxy pale skin, hair thinning (including lateral third of eyebrows), myxoedema* (all signs of hypothyroidism)
  • Eyes (all signs of thyrotoxicosis)
    • Lid retraction of upper eye-lid 
    • Exophthalmos (sclera visible above and below iris)
    • Proptosis (forward protrusion of eye; inspect from above and side)
    • Chemosis/conjunctival oedema 
  • Extra-ocular muscles:
    • Perform H-test and ask about diplopia to test for ophthalmoplegia
    • Test central vertical eye movement (โ€˜lid lagโ€™ on downward vertical gaze = thyrotoxicosis)

Neck

Inspection

Inspect from anteriorly

  • Swellings and scars
  • Ask patient to swallow (thyroid andย thyroglossal cysts move on swallowing)
  • Stick out tongue (thyroglossal cysts move on tongue protrusion)
  • Place their hands above their head (Pembertonโ€™s sign = retrosternal goitre compressesย superior vena cavaย and results in venous congestion)

Palpationย 

Palpate from posteriorly

  • Palpate thyroid gland (over 2nd, 3rdย and 4thย tracheal cartilages), including feel while patient swallows and sticks out tongue
  • Full cervical lymph node exam

Percussion

Percuss over sternum for retrosternal goitre

Auscultation

Auscultate forย thyroid bruit over each lobe

Finally

  • Proximal myopathy: test resisted shoulder abduction, then ask patient to stand up from chair with arms crossed (hypothyroidism or hyperthyroidism)
  • Reflexes (brisk in hyperthyroidism; slow-relaxing in hypothyroidism)
  • Look for pretibial myxoedema (Gravesโ€™ disease)

To complete

  • Thank patient
  • Summarise and suggest further investigations you would consider after a full history (e.g. TFTs, thyroid USS)

Questions

What pathological conditions are associated with an abnormal thyroid exam?

Oops! This section is restricted to members. Click here to signup!

Please state 5 clinical signs linked to hyperthyroidism?

Oops! This section is restricted to members. Click here to signup!

What are the clinical signs specific to Gravesโ€™ disease?

Oops! This section is restricted to members. Click here to signup!

How do thyroglossal cysts form? How could you confirm a lesion is a thyroglossal cyst on clinical examination?

Oops! This section is restricted to members. Click here to signup!

Why may Gravesโ€™ disease cause a bruit when auscultating the thyroid gland?

Oops! This section is restricted to members. Click here to signup!

Now you’re ready for some OSCE stations!

  1. Normal thyroid exam
  2. Graves’ disease
  3. Hashimoto’s thyroiditis
  4. Our subscribers enjoy hundreds of stations!

Picture references

Exophthalmos: Jonathan Trobe, M.D. University of Michigan Kellogg Eye Center. The Eyes Have It 2011. Licensed under the Creative Commons Attribution 3.0 Unported license (https://creativecommons.org/licenses/by/3.0/deed.en). Sourced from: https://en.m.wikipedia.org/wiki/File:Proptosis_and_lid_retraction_from_Graves%27_Disease.jpg

No comments yet ๐Ÿ˜‰

Leave a Reply