Thyroid examination Flashcards by Bethany Smith

What are the first step in the introduction?

Wash hands

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Introduce yourself

Hello, I’m _____ _____ a third year medical student .

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What details do you need to confirm from the patient?

Name
DOB (Age)

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When listening to the patient what type of voice would indicate HYPOthyroidism?

Hoarse

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Explain the thyroid examination

Today I’ve been asked to examine the thyroid gland in your neck is that okay?

This involves me generally inspecting you then moving closer to have a look of the neck then a feel of the neck as well

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How should a pt be positioned in a thyroid exam?

Comfortably on a chair so that you can walk around on all sides.

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What equipment is needed for a thyroid exam?

Stethoscope.
Glass of water.
Tendon hammer.
A4 piece of paper.

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On general inspection what would we look for?

Build,
Clothing that is inappropriate for the given temperature, Restlessness,
Confusion,
Hair/skin quality.

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If someone seems hyperactive what does this indicate?

(thyroid exam)

HYPERactive = HYPERthyroidism.

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Name some of the hand signs present in a person with HYPOthyroidism

Dry skin
Brittle nails

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Name some of the hand signs present in a person with HYPERthyroidism

Increased sweating / Temperature
Palmar erythema
Onycholysis

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What hand sign would you specifically see in Graves’ disease?

Thyroid acropachy (presents as clubbing)

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How would you inspect for a tremor?

Hands outstretched + pronated.
Hands outstretched + pronated.

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In a thyroid exam if a tremor is present what does it indicate?

Hyperthyroidism

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When feeling the radial pulse what would the following indicate?

a - bradycardia
b - tachycardia

(thyroid exam)

a - HYPOthyroidism

b - HYPERthyroidism

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If a person has hyperthyroidism what type of irregularly irregular pulse rhythm might you feel?

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What are you inspecting for in the forearms and what does it indicate?

Muscle wasting

Hyperthyroidism

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What would you inspect for when looking at the face in a thyroid exam?

HYPER
- Sweating

HYPO
- Dry skin
- Loss of outer 1/3 of
eyebrow

Inspecting the eyes what do we look for?

Exophthalmos
Chemosis
Lid retraction

What is the best way to inspect the eyes for exophthalmos?

Inspect from the front both sides and the back and finally ask the pt to look slightly up whilst you stand behind them.

How do we test eye movements?

Ask patient to keep head still and follow finger with eyes.

Move finger in “H” shape to test various axes of eye movement.

Observe for restriction of movements

Ask patient to report any diplopia/pain.

How do we test for lid lag?

What does lid lag look like?

Ask patient to keep head still and follow finger with eyes.

Hold finger high + move finger downwards.

Delayed downward movement of the eyelids

When closely inspecting the neck what are you looking for?

skin changes - erythema
Scars = thyroidectomy
Masses - LN / goitre

normal thyroid gland shouldn’t be visible

How do you perform a water test?

Ask patient to take some water in their mouth + then observe the neck while they swallow it.

When looking at masses during the water test which masses move with swallowing and which don't move much?

Thyroid masses + thyroglossal cysts move WITH swallowing. Lymph nodes will move very little.

How do you perform a tongue test?

Ask patient to protrude their tongue

When looking at masses during the tongue test which masses move up and which don't move?

Thyroid gland masses/lymph nodes will NOT move. Thyroglossal cysts will move upwards noticeably.

What else should we inspect the mouth for in a thyroid exam?

A lingual thyroid at the back of the tongue

How do you palpate the thyroid?

Stand behind the patient + ask them to slightly flex their neck (to relax sternocleidomastoids). Place hands on either side of the neck + ask if pain before palpating. Place the 3 middle fingers of each hand along the midline of the neck below the chin + locate the upper edge of the thyroid cartilage. Move inferiorly until the cricoid cartilage is reached. The first two rings of the trachea are located below the cricoid cartilage + the thyroid isthmus overlies this area. Palpate thyroid isthmus using pads of your fingers + palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus.

When palpating the thyroid what are you assessing?

Size + site Masses Consistency Mobility Position Redo water test whilst palpating Redo tongue test whilst palpating

What lymph nodes do we palpate during a thyroid exam?

Supraclavicular. Anterior cervical chain. Posterior cervical chain. Submental nodes.

What else would we want to palate in a thyroid exam?

Trachea for any deviation

Where do we percuss on a thyroid exam?

Percuss downwards from the sternal notch.

On percussion of the sternum what may retrosternal dullness indicate? (thyroid exam)

retrosternal extension of goitre

What do you auscultate in a thyroid exam What directions should you give the the patient? If a bruit is heard what does this suggest?

Each lobe of the thyroid Hold their breath Increased vascularity which is secondary to Graves’ disease.

What special tests do you perform in a thyroid exam?

Reflexes Inspect for pretibial myxoedema Proximal myopathy.

what reflex do you test in a thyroid exam?

Bicep reflex Could alternatively check ankle

what would hyporeflexia indicate?

hypothyroidism

what is pretibial myxoedema associated with?

Graves' disease

How do you assess for proximal myopathy?

Ask patient to stand from sitting position with arms crossed.

What does proximal myopathy test for? What is a positive test? If they test positive what does it indicate?

proximal muscle wasting Inability to stand from a sitting position with arms crossed proximal myopathy

Once the exam in complete what are the first steps to do?

Thank patient Wash hands

To complete my exam...

I would perform fundoscopy and conduct some blood tests for TSH/T4 levels. IF NEEDED - I would also request an ECG (if irregular pulse noted). Further imaging (ultrasound scan).

Summarise a normal thyroid exam

I performed a thyroid examination on ___ who is a ___ year old ____ On general inspection, ____ appeared well at rest There were no peripheral stigmata of thyroid pathology The pulse was of normal rate and rhythm and was ___bpm No evidence of tremor or thyroid eye disease On palpation, there was no evidence of goitre or any other swelling On percussion, there was no evidence of retrosternal goitre On auscultation, there was no evidence of bruits In summary, this was a normal thyroid examination