Thyroid Examination Flashcards
What should be included in the introduction of a thyroid examination?
- Wash hands
- Introduce yourself
- Identify the patient
- Explain the exam
- Gather consent
- Place the patient sat in a chair
- Expose the neck
- Confirm well being
What 6 things should be noted on general inspection of the patient?
- Build
- Clothing
- Activity
- Mental state
- Quality of skin/hair
Weight loss and an increase in appetite is typical in which thyroid condition?
Hyperthyroidism
Weight gain and a decrease in appetite is typical in which thyroid condition?
Hypothyroidism
What may be significant with the clothing of someone with hyperthyroidism?
- Prefer a cooler environment due to increase in temperature
- Wear less clothes than appropriate for the weather
What may be significant with the clothing of someone with hypothyroidism?
- Prefer a warmer environment due to a decrease in temperature
- Wear more clothes than appropriate for the weather
What may hyperactivity indicate and what may be included in this (in a thyroid context)?
- May indicate hyperthyroidism
- Agitation, anxiety, restless
What is a ‘typical’ mental state for someone who is hypothyroid?
State of lethargy & depression
Confusion can occur in both hyperthyroid & hypothyroid - true or false?
True
What may fine hair/hair loss indicate in a thyroid exam?
Hyperthyroidism
What ,may a hoarse voice indicate in a thyroid exam?
Thyroid gland enlargement because of compression to the larynx
What are the three main things to be inspected on the hands in a thyroid exam?
- Hands & nails
- Peripheral tremor
- The radial pulse
What may dry skin & brittle nails indicate in a thyroid exam?
Hypothyroidism
What may increased sweating and & palmar erythema indicate in a thyroid exam?
Hyperthyroidism
What is palmar erythema?
Reddening of the palms of the hands
Name two non-thyroid causes of palmar erythema
- Chronic liver disease
- Pregnancy
What is thyroid acropachy?
Phalangeal bone overgrowth
In which condition do you see thyroid acropachy?
Grave’s disease
In which thyroid condition does onycholysis occur?
Hyperthyroidism
What is onycholysis?
Separation of the nail from the nail bed
How do you inspect the hands for a peripheral tremor in a thyroid exam?
- Place a piece of paper across the back of the patient’s hands to assess tremor
- Paper quivering = indicates tremor
What is the significance of a peripheral tremor on a thyroid exam?
May indicate hyperthyroidism
What are the three findings to measure for in a radial pulse in a thyroid exam?
- Bradycardia
- Tachycardia
- Atrial Fibrillation
What does bradycardia indicate in the context of a thyroid exam?
Sign of hypothyroidism
What does tachycardia indicate in the context of a thyroid exam?
Sign of hyperthyroidism
What does atrial fibrillation indicate in the context of a thyroid exam?
Thyrotoxicosis
If a pulse is irregular, how long should it be measured for?
60 seconds
What should be inspected on the face when doing at a thyroid exam?
- Dryness of skin
- Sweating
- Eyebrow fullness
What may dry skin indicate in the context of a thyroid exam?
Hypothyroidism
What may sweating indicate in the context of a thyroid exam?
Hyperthyroidism
What may the loss of the outer third of the eyebrows indicate in a thyroid exam?
Rare sign of hypothyroidism
What causes bilateral exophthalmos?
Abnormal deposition of connective tissue in the orbit and extra-ocular muscles
Name the eye pathologies associated with thyrotoxicosis
- Lid retraction
- Eye inflammation
- Exophthalmos
- Eye movement abnormalities
- Lid lag
What is exophthalmos?
Bulging of the eye anteriorly out of the orbit
What eye inflammation may be present in thyrotoxicosis?
- Conjunctival oedema (chemoses)
- Conjunctivitis
- Corneal ulceration
What issues with eye movement may arise in a thyroid exam?
- Evidence for ophthalmoplegia
- Pain during eye movement
What is ophthalmoplegia?
Paralysis or weakness of one or more of the eye muscles
How do you assess the eye movements in a thyroid exam?
- The ‘H’ test
- Create a H shape in the air, and get the patient to follow with their eyes
What is lid lag?
A delay in the descent of the upper eyelid in relation to the eyeball when looking down
How do you test lid lag?
- Place your finger high in the air
- Move it downwards and observe the patients upper eyelids
What should be noted on a general inspection of the thyroid?
- Inspect the midline of the neck
- Masses e.g. goitre
- Scars e.g. previous thyroidectomy
Should the thyroid gland be visible?
No
How is a thyroid gland further inspected?
By swallowing and tongue protrusion
How is swallowing used to assess the thyroid?
Watch the movement of the mass when swallowing water
What happens to thyroid gland masses & thyroglossal cysts when swallowing?
They move upwards
What happens to lymph nodes in the neck when swallowing?
They move very little
What happens to an invasive thyroid malignancy on swallowing?
May not move is tethered to surrounding tissue
What will happen when the tongue is protruded with a thyroglossal cyst?
Will move upwards noticeably
What will happen when the tongue is protruded with a thyroid gland mass/lymph node?
Will not move
How is the thyroid palpated?
- Chin down, approach from behind
- Place 3 middle fingers of each hand along the midline of the neck
- Locate upper edge of thyroid cartilage (Adam’s apple)
- Move fingers inferiorly until you reach cricoid cartilage
- Palpate the thyroid isthmus
- Palpate each lobe
- Ask the patient to swallow water while palpating
- Ask the patient to raise their tongue
What are the important characteristics of the thyroid?
- Size
- Symmetry
- Consistency
- Masses
- Palpable thrill
What is important about the size of the thyroid?
If it feels enlarged
What is important about the symmetry of the thyroid?
- Look for asymmetry
- Unilateral enlargement may be caused by a thyroid nodule or malignancy
What is important about the consistency of the thyroid?
- Note any widespread irregularities
- Widespread irregularity may indicate multi nodular goitre
Why is it important to assess for a palpable thrill in a thyroid exam?
Indicates increased vascularity due to hyperthyroidism
What needs to be assessed if a thyroid mass is noted?
Position, shape, consistency and mobility
Why are the lymph nodes palpated in a thyroid exam?
To assess for local lymphadenopathy which may indicate metastatic spread of primary thyroid malignancy
Which lymph nodes should be felt in a thyroid exam?
Around the jawline, back of the neck and the collarbones
What is the significance of tracheal deviation in a thyroid exam?
May be caused by a large goitre
Why is the sternum percussed in a thyroid exam?
- To assess for retrosternal dullness
- This may indicate a large thyroid mass, extending posteroinferiorly to the manubrium
Why should the thyroid gland be auscultated?
- To listen for a bruit
- This indicates increased vascularity, which usually occurs in Graves’
Why is a biceps reflex performed in a thyroid exam?
Due to hyporeflexia occurring due to hypothyroidism
How is a biceps reflex carried out?
- Relax the patient’s arm, locate the biceps brachia tendon
- Place the thumb of your non-dominant hand over the tendon and then tap your thumb with the tendon hammer
- Observe for a contract
What is the thyroid condition which may cause proximal myopathy?
A complication of mulitnodular goitre and Graves’ disease
How do you screen for proximal myopathy?
- Ask the patient to stand from a sitting position with their arms crossed
- An inability to stand up would suggest proximal muscle weakness
What further tests would be done after a thyroid exam?
- Thyroid function tests
- ECG to rule out AF if irregular pulse noted
What further imaging would be done after a thyroid exam?
An ultrasound of the neck to further assess any thyroid lumps
