Thyroid examination Flashcards
What are the first step in the introduction?
Wash hands
Introduce yourself
Hello, I’m _____ _____ a third year medical student .
What details do you need to confirm from the patient?
Name
DOB (Age)
When listening to the patient what type of voice would indicate HYPOthyroidism?
Hoarse
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
How should a pt be positioned in a thyroid exam?
Comfortably on a chair so that you can walk around on all sides.
What equipment is needed for a thyroid exam?
Stethoscope.
Glass of water.
Tendon hammer.
A4 piece of paper.
On general inspection what would we look for?
Build,
Clothing that is inappropriate for the given temperature, Restlessness,
Confusion,
Hair/skin quality.
If someone seems hyperactive what does this indicate?
(thyroid exam)
HYPERactive = HYPERthyroidism.
Name some of the hand signs present in a person with HYPOthyroidism
Dry skin
Brittle nails
Name some of the hand signs present in a person with HYPERthyroidism
Increased sweating / Temperature
Palmar erythema
Onycholysis
What hand sign would you specifically see in Graves’ disease?
Thyroid acropachy (presents as clubbing)
How would you inspect for a tremor?
Hands outstretched + pronated.
Hands outstretched + pronated.
In a thyroid exam if a tremor is present what does it indicate?
Hyperthyroidism
When feeling the radial pulse what would the following indicate?
a - bradycardia
b - tachycardia
(thyroid exam)
a - HYPOthyroidism
b - HYPERthyroidism
If a person has hyperthyroidism what type of irregularly irregular pulse rhythm might you feel?
AF
What are you inspecting for in the forearms and what does it indicate?
Muscle wasting
Hyperthyroidism
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
