Table of Contents
Introduction
- Wash hands
- Introduce self
- Ask Patient’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 patient’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 patient’s hands (fine tremor = thyrotoxicosis).
- Nails: thyroid acropachy (Graves’ 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 (‘lid lag’ on downward vertical gaze = thyrotoxicosis)
Neck
Inspection
Inspect from anteriorly
- Swellings and scars
- Ask patient to swallow (thyroid and thyroglossal cysts move on swallowing)
- Stick out tongue (thyroglossal cysts move on tongue protrusion)
- Place their hands above their head (Pemberton’s sign = retrosternal goitre compresses superior vena cava and results in venous congestion)
Palpation
Palpate from posteriorly
- Palpate thyroid gland (over 2nd, 3rd and 4th 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 for 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 (Graves’ 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?
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Please state 5 clinical signs linked to hyperthyroidism?
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What are the clinical signs specific to Graves’ disease?
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How do thyroglossal cysts form? How could you confirm a lesion is a thyroglossal cyst on clinical examination?
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Why may Graves’ disease cause a bruit when auscultating the thyroid gland?
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Picture references
Exophthalmos: Jonathan Trobe, M.D. The Eyes Have It 2011. Licensed under the Creative Commons Attribution 3.0 Unported license
