Thyroid Exam Flashcards
Basic Thyroid Examination
Thyroid Anatomy:
- The thyroid gland lies anterior to the larynx and trachea
- It is below the prominence of the cricoid cartilage
- The isthmus is midline anterior to the 2nd - 4th tracheal ring, and connects the right and left lobe
I. Inspection - Anterior: ○ engorged veins (retrosternal expansion) ○ Visible masses/swelling ○ Scars - Lateral: ○ Normal straight line from the cricoid cartilage to the suprasternal notch ○ Sip water: inspecting thyroid movement on swallowing § Normal: thyroid rises, pauses, then descends § Malignant thyroid CA: no movement due to adhesions II. Palpation - Stand behind the patient, place both hands with the pulp of the fingers on the gland while the head is slightly flexed - Use one hand to steady the gland and palpate with other hand - Palpate the right and left lobe and the isthmus 1. Characteristics: i. Size □ Lower border: if not felt, suggestive of retrosternal expansion ii. Consistency: (Hashimoto: rubbery) iii. Nodularity iv. Tenderness v. Mobility: ask the patient to sip water while I palpate the gland 2. Palpable Thrills: rumbling sensation (Hyperthyroidism with hypervascularity has thrills) 3. Cervical lymph nodes: feel for the 8 chains: submental, submandibular, jugular chain, posterior triangle, pre & post auricular, occipital, supraclavicular 4. Tracheal position: come to the front of the patient; with your forefingers, put it on the suprasternal notch, press backwards and upwards to see if trachea is in midline III. Percussion - Using the pad of right middle finger, strike firmly on the middle phalanx of the left middle finger - Percuss the manubrium of the sternum from side to side to find retrosternal expansion IV. Auscultation - Place stethoscope over each lobe - Listen for bruits (hyperthyroidism) V. Pemberton's sign (Thoracic Outlet Obstruction) - Ask the patient to raise his arms above his head ○ Expect to see cyanosis, flushing, inspiratory stridor, respiratory distress, engorged veins
Hyperthyroidism
Case 1: Patient came in due to anxiousness. TSH 0.01
Case 2: Patient complaining of something wrong with the nerves, with shakiness on his hands. Family history of thyroid disorders.
I. Introduction
- Introduce yourself
- Explain steps: I’ll be looking at your neck, feeling your neck, gently tapping on the neck
- Get consent
- Wash hands, start examination
II. Flagging - Anatomy: The thyroid is a butterfly gland in front of the neck. It has 2 lobes connected by the isthmus. The isthmus is below the cricoid cartilage in front of the 2nd-4th tracheal ring III. General Appearance - Anxious, sweaty face - Dressed appropriate to weather (heat intolerance) IV. Hands - Tremors: ask the patient to stretch out his arms and look for coarse tremors; place a paper on the hand looking for fine tremors - Onycholysis: separation of the nail from the nail bed - Thyroid acropachy & clubbing: swelling of the fingers and loss of the diamond-shaped space - Palmar erythema - Sweaty, moist, warm palm - Pulse rate for tachycardia, pulse rhythm (irregular rhythm: atrial fibrillation) V. Arms - Proximal myopathy: raise the arms above the head, if unable to do that, may be proximal myopathy - Biceps reflex: place thumb over the biceps tendon while the arm is resting on your forearm, tap on the biceps tendon -- look for hyperreflexia VI. Face - Eye examination: ○ Inspection: § exophthalmos: I'll look from behind over the patient's forehead looking for protrusion of the eyeball § Lid retraction: you can see the sclera above the cornea ○ Movement: § Ask the patient to hold the head still and follow the red top pin with his eyes, draw a big H shape, looking for ophthalmoplegia (restriction on eye movements) § While moving the pen down, the eyeball will move downwards but there is a lag in the lid movement, which allows me to see the upper sclera VII. Neck - Thyroid exam - see above VIII. Chest - Inspect for gynecomastia - Auscultation for the systolic flow murmur IX. Legs - Inspect for pretibial myxedema: elevated plaques and swelling on the lower limb below the knee
Hypothyroidism
Case 1: Patient complains of tiredness. TSH: 9 (N: 0.4 - 4)
Case 2: Patient complains of tiredness, constipation, difficulty concentrating, weight gain. Family history of thyroid disorders
I. Introduction
- Introduce yourself
- Explain steps: I’ll be looking at your neck, feeling your neck, gently tapping on the neck
- Get consent
- Wash hands, start examination
II. Flagging
- Anatomy: The thyroid is a butterfly gland in front of the neck. It has 2 lobes connected by the isthmus. The isthmus is below the cricoid cartilage in front of the 2nd-4th tracheal ring
III. General Appearance
- Dressed appropriate to weather (cold intolerance)
- Mental & physical sluggishness
- Hypothyroidism speech: slow, nasal & deep voice
IV. Hands
- Peripheral cyanosis (decreased CO)
- Swelling in fingers and hand
- Cold & dry skin
- Pale palmar crease
- Yellowish discoloration in the palm (hypercarotenemia due to decreased hepatic metabolism)
V. Arms
- Proximal myopathy: raise the arms above the head, if unable to do that, may be proximal myopathy
- Biceps reflex: place thumb over the biceps tendon while the arm is resting on your forearm, tap on the biceps tendon – look for slightly slow or normal contraction followed by a delayed relaxation
VI. Face
- Alopecia, hair loss of the outer 3rd of the eyebrows
- Vitiligo: hypopigmented patches
- Ophthalmoplegia
- Periorbital swelling/edema
- Xanthelasma (hypothyroidism is one of the most common cause of secondary hypercholesterolemia)
- Check tongue for swelling
VII. Neck
- Thyroid exam - see above
VIII. Chest
- Auscultation for muffled heart sounds suggestive of pericardial effusion
- Auscultation for decreased or absent breathing sounds suggestive of pleural effusion
IX. Legs
- Inspect for lower limb edema, check if pitting or non-pitting (hypothyroidism gives non-pitting edema)
- Achilles reflex: ask the patient to kneel on the chair with the foot hanging. Tap on the Achilles tendon with a reflex hammer. You will see a slightly slow contraction and delayed relaxation which will cause a “hung up reflex”
- I’d like to do a sensory neurological exam to check for sensory neuropathy (one differential of sensory neuropathy in the lower limb is hypothyroidism)
Neck Swelling Examination
Your next patient is a 40 year old man who presents to you complaining of a swelling and lump in his neck. He has difficulty in swallowing and has a family history of thyroid disease.
Task:
1. Explain your physical examination to the medical student
I. Introduction
- Introduce yourself
- Explain steps: I’ll be looking at your neck, feeling your neck, gently tapping on the neck
- Get consent
- Wash hands, start examination
II. Flagging - Anatomy: The thyroid is a butterfly gland in front of the neck. It has 2 lobes connected by the isthmus. The isthmus is below the cricoid cartilage in front of the 2nd-4th tracheal ring III. General Appearance - For hyperthyroidism, I'm looking for: ○ Anxious, sweaty face ○ Dressed appropriately to weather - For hypothyroidism, I'm looking for: ○ Mental and physical sluggishness ○ Deep, nasal voice IV. Hands - For hyperthyroidism, I'm looking for: ○ Tremors ○ Onycholysis, Thyroacropachy ○ Palmar erythema, sweaty moist palms - For hypothyroidism, I'm looking for: ○ Peripheral cyanosis ○ Cold & dry skin ○ Swelling in fingers and hand V. Arm - For both hyper and hypothyroidism, I'm looking for: ○ Proximal myopathy - I'll check the biceps reflex ○ Hyperthyroidism: hyperreflexia ○ Hypothyroidism: delayed relaxation phase of the reflex VI. Face - For hyperthyroidism, I'm looking for: ○ Exophthalmos, lid retraction ○ Ophthalmoplegia, lid lag - For hypothyroidism, I'm looking for: ○ Alopecia, loss of the outer third of the eyebrow ○ Periorbital swelling/edema ○ Xanthelasma VII. Neck A. Inspection - Anterior: ○ engorged veins (retrosternal expansion) ○ Visible masses/swelling ○ Scars - Lateral: ○ Normal straight line from the cricoid cartilage to the suprasternal notch ○ Sip water: inspecting thyroid movement on swallowing § Normal: thyroid rises, pauses, then descends § Malignant thyroid CA: no movement due to adhesions B. Palpation - Stand behind the patient, place both hands with the pulp of the fingers on the gland while the head is slightly flexed - Use one hand to steady the gland and palpate with other hand - Palpate the right and left lobe and the isthmus 1. Characteristics: i. Size □ Lower border: if not felt, suggestive of retrosternal expansion ii. Consistency: (Hashimoto: rubbery) iii. Nodularity iv. Tenderness v. Mobility: ask the patient to sip water while I palpate the gland 2. Palpable Thrills: rumbling sensation (Hyperthyroidism with hypervascularity has thrills) 3. Cervical lymph nodes: feel for the 8 chains: submental, submandibular, jugular chain, posterior triangle, pre & post auricular, occipital, supraclavicular 4. Tracheal position: come to the front of the patient; with your forefingers, put it on the suprasternal notch, press backwards and upwards to see if trachea is in midline C. Percussion - Using the pad of right middle finger, strike firmly on the middle phalanx of the left middle finger - Percuss the manubrium of the sternum from side to side to find retrosternal expansion D. Auscultation - Place stethoscope over each lobe - Listen for bruits (hyperthyroidism) E. Pemberton's sign (Thoracic Outlet Obstruction) - Ask the patient to raise his arms above his head ○ Expect to see cyanosis, flushing, inspiratory stridor, respiratory distress, engorged veins VIII. Chest - I'll do auscultation on the chest: ○ For hyperthyroidism, I'm listening for systolic flow murmur ○ For hypothyroidism, I'm listening for muffled heart sounds suggestive of pericardial effusion, and absent/decreased breath sounds suggestive of pleural effusion IX. Legs - For hyperthyroidism, I'm looking for: ○ Pretibial myxedema - For hypothyroidism, I'm looking for: ○ Non-pitting edema ○ Hung up reflex of the Achilles reflex
