THYROID EXAMINATION

Question 1

How would you start any examination?

Answer 1

WIPER QQ
Wash hands
Introduce yourself
Ask permission
Expose the patient
Reposition the patient

Ask if they are in any pain or discomfort

Question 2

How exposed should the patient be for the thyroid examination?

Answer 2

You need their neck to be exposed.

Question 3

How should the patient be positioned for thyroid examination?

Answer 3

They should be sitting up on a chair

Question 4

What might you look for during general inspection of the patient in a thyroid examination?

Answer 4

Hyperthyroidism:
Agitated
Anxious
Fidgety
Not enough clothes for weather
Proptosis - anterior displacement of the eyeball

Hypothyroidism:
Slow/lethargic
Too many clothes for weather
Thin hair

Both:
Scars on neck from previous surgery
Goitre

Question 5

What are you looking for in the hands during a thyroid examination?

Answer 5

Dryness - Hypo
Sweaty - Hyper
Palmar erythema
Tremor
Thyroid acropachy - a bit like clubbing
Temperature

Question 6

Is palmar erythema an indication of hypo or hyperthyroidism?

Answer 6

Hyper

Question 7

How should assess tremor during a thyroid examination?

Answer 7

Ask them to place their hands out in front of them, then put a piece of paper over both hands and look for trembling.

Question 8

Would peripheral tremor be a sign of hypo or hyperthyroidism?

Answer 8

Hyper

Question 9

What is thyroid acropathy a sign of?

Answer 9

Graves’ disease

Question 10

Having inspected the hands, what would you then do as part of the thyroid examination? What would you look for?

Answer 10

Assess the radial pulse
Tachycardia - hyper
Bradycardia - hypo
Atrial fibrillation

Question 11

What is the arrhythmia most commonly associated with hyperthyroidism?

Answer 11

Atrial fibrillation

Question 12

Having taken the patient’s radial pulse during a thyroid exam, what would you do next? What might you find?

Answer 12

Inspect the face
Dry skin - hypo
Sweating - hyper
Loss of outer third of eyebrow - hypo

Question 13

What might the loss of the outer third of the patient’s eyebrows be a clinical sign?

Answer 13

Hypothyroidism

Question 14

What might you look for in the eyes of someone whose thyroid you were examining?

Answer 14

Exophthalmos - lid lag
Redness
Inflammation of the conjunctiva
Double vision with eye movement

Question 15

What is exophthalmos, sometimes seen during a thyroid examination? What is it associated with?

Answer 15

Anterior displacement of the eye out of the orbit - must inspect from front, side and above
Associated with Graves’

Question 16

Why do we check eye movement as part of the thryoid examination?

Answer 16

Eye movement can be restricted in Graves’ disease due to abnormal connective tissue deposition in the orbit and extra-ocular muscles

Question 17

How do you test for lid lag as part of a thyroid examination?

Answer 17

Ask patient to look up at your finger with head still
Move finger downwards
Observe upper eyelid as the patient follows your finger downwards

Question 18

Having inspected the eyes and face as part of an examination of the thyroid, what would you do next?

Answer 18

Inspect the thyroid

Question 19

What are you looking for during inspection of the thyroid in a thyroid examination

Answer 19

Any skin changes
Any swellings or masses
Any scars from previous thyroid surgery

Question 20

If a mass in the thyroid area is noted on inspection during a thyroid exam, what would you get the patient to do? Why would you do this?

Answer 20

A swallow test - to distinguish a thyroid mass or thyroglossal cyst from a lymph node.
The lymph node would not move very much during swallowing action, whereas the thyroid does.

Question 21

How would you palpate the thyroid during examination?

Answer 21

Ask if patient has any pain
Stand behind the patient and ask them to slightly flex their neck (relaxing sternocleidomastoids)
Place both hands either side of neck
Locate thyroid cartilage (Adam’s apple) using three fingers
Move inferiorly until you reach cricoid cartilage (ring)
Palpate each lobe of thyroid in turn by moving fingers out laterally from isthmus
Ask patient to swallow again whilst palpating looking for symmetrical elevation of thyroid lobes
Ask patient to stick out tongue (thyroglossal cyst will rise)

Question 22

What are you assessing about the thyroid gland during palpation?

Answer 22

Size - goitre
Symmetry 
Consistency - multinodular goitres
Masses - distinct masses
Palpable thrill - hyperthyroidism

Question 23

Having palpated the thryoid gland as part of a thyroid examination, what would you do next?

Answer 23

Palpate the supraclavicular, anterior cervical, posterior cervical and submental lymph nodes looking for any lymphadenopathy which may suggest metastatic spread of thyroid malignancy

Question 24

Having palpated the lymph nodes as part of a thyroid examination, what would you do next? Why?

Answer 24

Palpate trachea looking for deviation caused be a thyroid mass

Question 25

Having palpated the trachea as part of a thyroid examination, what would you do next? Why?

Answer 25

Percuss the sternum. Dullness might indicate a large thyroid mass, extending posterior to the manubrium

Question 26

Having percussed the sternum as part of a thyroid examination, what would you do next? Why?

Answer 26

Ausculate each lobe of the thyroid for bruits

Question 27

What special tests might you do at the end of the thyroid examination? State why in each case.

Answer 27

Test reflexes - hyporeflexia seen in hypothyroidism
Inspect for pre-tibial myxodema - associated with Graves’
Test for proximal myopathies - proximal muscle weakness associated with hyperthyroidism

Question 28

What test would you say you would do in an OSCE at the end of a thyroid examination?

Answer 28

Blood tests to look for TSH, T3 and T4

Question 29

What does raised TSH and reduced T3 and T4 indicate?

Answer 29

Primary hypothyroidism

Question 30

What does reduced or normal TSH and reduced T3 and T4 indicate?

Answer 30

Secondary hypothyroidism

Question 31

What does reduced TSH and raised T3 and T4 indicate?

Answer 31

Hyperthyroidism