Thyroid Examination

Question 1

Anatomy of thyroid

Answer 1

Butterfly shaped gland
Isthmus running through middle
Closely related to carotid arteries
Sits near cricothyroid membrane

Question 2

What does the thyroid gland sit close to

Answer 2

The trachea
Thyroid is vascular

Question 3

What does thyroid contain?

Answer 3

Colloid filled follicles with thyroid filled hormones
Follicular and parafollicular cells

Question 4

3 main presentations of Thyroid disease

Answer 4

1. Lump in neck or mass effect
   - unilateral mass
   - bilateral mass - enlarged thyroid = goitre
   - symmetrical or asymmetrical
2. Hypo or Hyperthyroidism
3. Graves specific features

Question 5

What does hyperthyroidism and hypothyroidism usually present with?

Answer 5

Hyper = goitre
Hypo - often no goitre

Question 6

Questions for lump in neck

Answer 6

When did it start?
How quickly is it changing if at all?
Any FH?
Any pain?
Slow or sudden onset
Sudden onset could be due to bleed into thyroid nodule
Slow could be due to malignancy

Question 7

Lump in neck - history

Answer 7

Diffculty in breathing and swallowing?
Pain - thyroiditis and cancer
Incidental finding on CT/ TXR

Question 8

Where is a thyroglossal cyst found?

Answer 8

Found just above normal thyroid position?

Question 9

Symptoms of hypothyroidism?

Answer 9

Tired
Weight gain
Lethargy
Bad concentration
Depression
Cold intolerance
Headaches
Menorrhagia
Constipation
Dry skin
Hoarse voice
Pallor/ lightness of skin (Peaches and cream)

Question 10

Questions to ask for hypothyroidism and hyper?

Answer 10

How long have symptoms been present?
Speed of onset?
Previous treatment for overactive thryoid?
Previous medication - amiodarone (causes both) and lithium
FH of AI disease - thyroid and B12 deficiency, vitiligo Type 1, addisons
Loss of eyebrow hair - hypo only

Question 11

Primary causes of hypothyroidism?

Answer 11

Dyshormonogenesis
Iodine deficiency
AI
Post radioactive iodine
Post thyroidectomy

Question 12

Secondary and teriary causes of hypothyroidism

Answer 12

Pituitary tumours
Pituitary granulomas
Empty sella
Isolated TRH deficiency
Hypothalamic disorders

Question 13

What is the presentation of hypothyroidism?

Answer 13

Symptoms often vague and insidious
Screening in assosicated condiitions - Type 1, pernicious anaemia, addisons, vitiligo,

Question 14

Symptoms of hyperthyroidism

Answer 14

Weight loss
Sweating
Palpitations AF
Tremor
Anxiety
Lack of conc
Diarrhoea loose stool
Amenorrhoea
Muscle weakness

Question 15

Causes of hyperthyroidism

Answer 15

Common:
AI - Graves, postpartum thyroiditis
Toxic nodular goitre
Toxic adenoma

Rare@
Amiodarone induced
De Quervains
Thyrotroph adenoma
hCG hyperthyroidism
- hydatidiform mole
- choriocarcinoma

Question 16

Graves specific features

Answer 16

Proptosis (eyes)/ exopthalmos - bilateral or unilateral
Pain
Grittiness
Change in vision especially colour
Thyroid acropachy - changes in nail, look like clubbing
Pre tibial myxoedema - Skin changes

Question 17

Examination 1 - general

Answer 17

Clean hands - wash or alcohol
Check wheter any pain or tenderness in hands or neck
Patient seated
Face patient
General appearance - calm? restless? confused/ agitated?

Question 18

Examination 2. hands inspection

Answer 18

Sweating - hyper
Palmar erythema
Thyroid acropachy - graves
Brittle nails - hypothyroid - Fe def
Pulse - bradycardia, tachycardia or AF
Tremor - hands outstretched

Question 19

Examination 3. Thyroid

Answer 19

Inspect neck - masses, welling, scars
Ask patient to take water into mouth and hold it and then swallow it - does mass move up when swallowing
Ask patient to project tongue - if midline mass moves up - thyroglossal cyst
Ask patient to open mouth - lingual thyroid back of tongue
From behind patient:
Palpate thyroid - ask if theres any pain or discomfort
Palpate trachea - deviated
Ask patient to take water into mouth - hold then swallow whilst palpating hands and fingers still

Question 20

If theres a thyroid mass how do you evaluate?

Answer 20

Check its:
Size
Shape
Surface
Consistency
Hard soft firm?
Fixed to skin?
Can you get above or below it?
Any lymph node enlargement?

Question 21

Thyroid examination 4

Answer 21

Examine for exopthalmos
Auscultation - ? Bruit - with patient briefly holding breath
Bruit - sound made through rapid blood flow through part of body - found in thyroid or neck vessels - swishing sounds indicative of bruit

Question 22

Examination of eyes

Answer 22

Evidence of thyroid eyes disease?
Conjunctival oedema
Eye movements - ? diplopia
Acuity and fundoscopy
Check for lid lag - a sign of thyrotoxicosis - eye lids lagging behind rest of eye - hyperthyroidism in any form
Lid retraction - any form hyperthyroidism