Thyroid examination

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)

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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

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)

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

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Questions

Now you’re ready for some OSCE stations!

1. Normal thyroid exam
2. Graves’ disease
3. Hashimoto’s thyroiditis
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