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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)

Face

  • Generally: waxy pale skin, hair thinning (including lateral third of eyebrows), myxoedema* (all signs of hypothyroidism)
  • Eyes
    • Lid retraction of upper eye-lid (thyrotoxicosis)
    • 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 (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 (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
  • If you feel a mass/swelling,note its characteristics (SSSCCCTTT)
    • Size, Shape, Surface, Consistency, Contours, Colour, Temperature, Tenderness, (Transillumination not required for thyroid)
  • Percussion over sternum: for retrosternal goitre
  • Auscultation: 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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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. The Eyes Have It 2011. Licensed under the Creative Commons Attribution 3.0 Unported license

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