THYROID EXAMINATION Flashcards
How would you start any examination?
WIPER QQ Wash hands Introduce yourself Ask permission Expose the patient Reposition the patient
Ask if they are in any pain or discomfort
How exposed should the patient be for the thyroid examination?
You need their neck to be exposed.
How should the patient be positioned for thyroid examination?
They should be sitting up on a chair
What might you look for during general inspection of the patient in a thyroid examination?
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
What are you looking for in the hands during a thyroid examination?
Dryness - Hypo Sweaty - Hyper Palmar erythema Tremor Thyroid acropachy - a bit like clubbing Temperature
Is palmar erythema an indication of hypo or hyperthyroidism?
Hyper
How should assess tremor during a thyroid examination?
Ask them to place their hands out in front of them, then put a piece of paper over both hands and look for trembling.
Would peripheral tremor be a sign of hypo or hyperthyroidism?
Hyper
What is thyroid acropathy a sign of?
Graves’ disease
Having inspected the hands, what would you then do as part of the thyroid examination? What would you look for?
Assess the radial pulse
Tachycardia - hyper
Bradycardia - hypo
Atrial fibrillation
What is the arrhythmia most commonly associated with hyperthyroidism?
Atrial fibrillation
Having taken the patient’s radial pulse during a thyroid exam, what would you do next? What might you find?
Inspect the face
Dry skin - hypo
Sweating - hyper
Loss of outer third of eyebrow - hypo
What might the loss of the outer third of the patient’s eyebrows be a clinical sign?
Hypothyroidism
What might you look for in the eyes of someone whose thyroid you were examining?
Exophthalmos - lid lag
Redness
Inflammation of the conjunctiva
Double vision with eye movement
What is exophthalmos, sometimes seen during a thyroid examination? What is it associated with?
Anterior displacement of the eye out of the orbit - must inspect from front, side and above
Associated with Graves’
Why do we check eye movement as part of the thryoid examination?
Eye movement can be restricted in Graves’ disease due to abnormal connective tissue deposition in the orbit and extra-ocular muscles
How do you test for lid lag as part of a thyroid examination?
Ask patient to look up at your finger with head still
Move finger downwards
Observe upper eyelid as the patient follows your finger downwards
Having inspected the eyes and face as part of an examination of the thyroid, what would you do next?
Inspect the thyroid
What are you looking for during inspection of the thyroid in a thyroid examination
Any skin changes
Any swellings or masses
Any scars from previous thyroid surgery
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?
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.
How would you palpate the thyroid during examination?
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)
What are you assessing about the thyroid gland during palpation?
Size - goitre Symmetry Consistency - multinodular goitres Masses - distinct masses Palpable thrill - hyperthyroidism
Having palpated the thryoid gland as part of a thyroid examination, what would you do next?
Palpate the supraclavicular, anterior cervical, posterior cervical and submental lymph nodes looking for any lymphadenopathy which may suggest metastatic spread of thyroid malignancy
Having palpated the lymph nodes as part of a thyroid examination, what would you do next? Why?
Palpate trachea looking for deviation caused be a thyroid mass
Having palpated the trachea as part of a thyroid examination, what would you do next? Why?
Percuss the sternum. Dullness might indicate a large thyroid mass, extending posterior to the manubrium
Having percussed the sternum as part of a thyroid examination, what would you do next? Why?
Ausculate each lobe of the thyroid for bruits
What special tests might you do at the end of the thyroid examination? State why in each case.
Test reflexes - hyporeflexia seen in hypothyroidism
Inspect for pre-tibial myxodema - associated with Graves’
Test for proximal myopathies - proximal muscle weakness associated with hyperthyroidism
What test would you say you would do in an OSCE at the end of a thyroid examination?
Blood tests to look for TSH, T3 and T4
What does raised TSH and reduced T3 and T4 indicate?
Primary hypothyroidism
What does reduced or normal TSH and reduced T3 and T4 indicate?
Secondary hypothyroidism
What does reduced TSH and raised T3 and T4 indicate?
Hyperthyroidism
