Thyroid examination

Question 1

Thyroid examination - general inspection?

Answer 1

Hyper: Anxious, agidtated, fidgity

Question 2

Hand signs on thyroid examination?

Answer 2

Acropatchy (swelling and clubbing of hands) - Graves
Peripheral tremor - hyperthyroid
Dry skin - hypo
Palmar erythema - hyper

Question 3

Components of thyroid examination?

Answer 3

1. General inspection
2. Hand signs
3. Pulse
4. Inspection of face
5. Inspect eyes
6. Eye movement (lid lag)
7. Inspection of the neck
8. Watch patient swallow and stick tongue out
9. Palpation of thyroid and lymph nodes
10. Percussing down the sternum (massive goitre if dull)
11. Listen for bruit
12. Test bisceps tendon reflexes
13. Inspect legs
14. Ask patient to stand with arms crossed

Question 4

Facial signs on thyroid examination?

Answer 4

Sweating - hyper
Dry skin - hypo
Loss of outer third of eyebrow - hypo

Question 5

Eye inspection - thyroid?

Answer 5

Lid retraction (front)
Inspect for anterior displacement of the eye out of the orbit (exopthalmos)

Question 6

Inspection of the neck (thyroid)

Answer 6

Skin changes -erythema
Scars
Masses (goitre/lymph node)

Question 7

Movement of thyroid mass on swallow but not tounge protusion?

Answer 7

Thyroid gland mass
Lymph nodes RARELY move
Thyroid mallginancy may not move due to tethering to surround tissue

Question 8

Thyroid lump the moves on swallow and tongue protusion?

Answer 8

Thyroglossal duct cyst?

Question 9

How to palpate the neck in thyroid examination?

Answer 9

Flex neck forward and relax
Begin palpation at thyroid cartillage (adams apple)
Move downwards until reach the superior edge of the cricoid cartillage
Below that is the isthmus of the thryoid gland - feel laterally - each thyroid lobe
Ask pt to protude tounge again and swallow water
Palpate lympth nosed for lymphadenopathy (thyroid malignancy)

Question 10

When might thryoid bruit be heard?

Answer 10

Graves disease

Question 11

Why do you test bisceps tendon reflexes in a thyroid examination?

Answer 11

Hyporeflexia- hypothyroidism

Question 12

What might be found o/e of the legs of a thyroid pt?

Answer 12

Pretibial myoxedema in graves disease?

Question 13

Why do you ask the patient to cross their arms and stand up in a thyroid examination?

Answer 13

To assess for proximal myopathy - hyperthyroidism

Question 14

Clinical signs on general inspection of thyroid patient?

Answer 14

Weight: weight loss is typically associated with hyperthyroidism (increased metabolism), whilst weight gain is associated with hypothyroidism (decreased metabolism).
Behaviour: anxiety and hyperactivity are associated with hyperthyroidism (due to sympathetic overactivity). Hypothyroidism is more likely to be associated with low mood.
Clothing: may be inappropriate for the current temperature. Patients with hyperthyroidism suffer from heat intolerance whilst patients with hypothyroidism experience cold intolerance.
Hoarse voice: caused by compression of the larynx due to thyroid gland enlargement (e.g. thyroid malignancy).

Question 15

Hand signs associated with HYPERthyroid

Answer 15

Thyroid acropachy: similar in appearance to finger clubbing but caused by periosteal phalangeal bone overgrowth secondary to Graves’ disease.
Onycholysis: painless detachment of the nail from the nail bed associated with hyperthyroidism.
Palmar erythema: reddening of the palms associated with hyperthyroidism, chronic liver disease and pregnancy.

Question 16

Why do you check radial pulse when examining the thyroid?

Answer 16

Bradycardia- hypo
Tachycardia - hyper
Irregular - AF associated with hyper

Question 17

Lid retraction

Answer 17

To identify lid retraction inspect the eyes from the front and note if sclera is visible between the upper lid margin and the corneal limbus (this indicative of lid retraction).

Upper eyelid retraction is the most common ocular sign of Graves’ disease however it can be present in other thyrotoxic states (e.g. toxic multinodular goitre). Eyelid retraction is thought to occur due to sympathetic hyperactivity causing excessive contraction of the superior tarsal and levator palpebrae superioris muscles.

Question 18

Expothalmos

Answer 18

To identify exophthalmos, inspect the eye from the front, the side and from above.

Exophthalmos is bulging of the eye anteriorly out of the orbit. Bilateral exophthalmos develops in Graves’ disease, due to oedema and lymphocytic infiltration of orbital fat, connective tissue and extraocular muscles.

Question 19

Eye inflamation

Answer 19

Inspect for evidence of inflammation affecting the eyes.

Due to lid retraction and exophthalmos, the eye is more prone to dryness and the development of conjunctival oedema (chemosis), conjunctivitis and in severe cases corneal ulceration.

Question 20

Why do you test eye movements in thyroid examination?

Answer 20

Assess for evidence of ophthalmoplegia (e.g. restricted eye movement, diplopia) and pain during eye movement caused by Graves’ disease (lymphocytic infiltration of orbital fat, connective tissue and extraocular muscles)

Question 21

Lid lag

Answer 21

Lid lag refers to a delay in the descent of the upper eyelid in relation to the eyeball when looking downward. Lid lag is most commonly associated with Graves’ disease although it can be present in other thyrotoxic states (e.g. toxic multinodular goitre). Lid lag is thought to occur secondary to a combination of lid retraction and exophthalmos.

To assess for evidence of lid lag:

1. Hold your finger superiorly and ask the patient to follow it with their eyes, whilst keeping their head still.
2. Move your finger in a downwards direction whilst observing the patient’s upper eyelids as the patient’s eyes follow your finger. If lid lag is present, the upper eyelids will be observed lagging behind the eyes’ downward movement, with the sclera being visible between the upper lid margin and the corneal limbus.

Question 22

Characteristics of the thyroid gland?

Answer 22

Size: note if the thyroid gland feels enlarged.
Symmetry: assess for any evidence of asymmetry between the thyroid lobes (unilateral enlargement may be caused by a thyroid nodule or malignancy).
Consistency: assess the consistency of the thyroid gland tissue, noting any irregularities (e.g. a widespread irregular consistency would be suggestive of a multinodular goitre).
Masses: note if there are any distinct palpable masses within the thyroid gland’s tissue (e.g. solitary thyroid nodule or thyroid malignancy).
Palpable thrill: assess for evidence of a palpable thrill caused by increased vascularity of the thyroid gland due to hyperthyroidism (suggestive of Graves’ disease)

Question 23

Unilateral thyroid lump

Answer 23

Mallignancy?

Thyroid nodule?

Question 24

Widespread irregular consistency of thyroid gland tissue is suggestive of what?

Answer 24

Multinodular goitre

Question 25

Type of goitre

Answer 25

Diffuse goitre: the whole thyroid gland is enlarged due to hyperplasia of the thyroid tissue.
Uninodular goitre: the presence of a single thyroid nodule which may be active (toxic) autonomously producing thyroid hormones (causing hyperthyroidism) or inactive.
Multinodular goitre: the presence of multiple thyroid nodules which may be active or inactive. Active multinodular goitres are often referred to as a toxic multinodular goitre.

Question 26

Why might a thyroid patient have a deviated trachea?

Answer 26

Large goitre

Question 27

Further investigations following thyroid examination?

Answer 27

Thyroid function tests: these include TSH, T3 and T4.
ECG: should be performed if an irregular pulse was noted to rule out atrial fibrillation.
Further imaging: an ultrasound scan of the neck to further assess any thyroid lumps.