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 (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)

Goitre

Exophthalmos

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 2^nd, 3^rd and 4^th 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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Now you’re ready for some OSCE stations!

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