Thyroid examination

Question 1

Thyroid examination: inspection of the thyroid gland

Answer 1

The patient should be sitting upright on a chair or the edge of a bed.
Look at the thyroid region.
If the gland is quite enlarged (goitre), it may protrude as a swelling just below the thyroid cartilage.
The normal thyroid gland is neither visible nor palpable.
The gland lies 2-3 cm below the thyroid cartilage and has 2 equal lobes connected by a narrow isthmus.
If a localised or generalised swelling is visible, ask the patient to take a mouthful of water then swallow- watch the neck swelling carefully.
Also ask the patient to stick out their tongue and watch the neck swelling.
The thyroid is attached to the thyroid cartilage of the larynx and will move up with swallowing.
Other neck masses such as an enlarged lymph node will hardly move.
Thyroglossal cysts will not move with swallowing by will move upwards with protrusion of the tongue.

Question 2

Thyroid examination: inspection of the rest of the neck

Answer 2

Carefully inspect the neck for any obvious scars (thyroidectomy scars are often hidden below a necklace and are easily missed).
Look for the JVP and make note of dilated veins which may indicate retrosternal extension of a goitre.
Redness or erythema may indicate suppurative thyroiditis.

Question 3

Thyroid examination: palpation of the thyroid gland

Answer 3

Always begin palpation from behind.
Stand behind the patient and place a hand either side of their neck.
The patient’s neck should be slightly flexed to relax the sternomastoids.
Explain what you are doing.
Ask if there is any tenderness.
Place the middle 3 fingers of either hand along the midline of the neck, just below the chin.
Gently ‘walk’ your fingers down until you reach the thyroid gland.
If the gland is enlarged ,determine if it is symmetrical.
Are there any discrete nodules?
Assess the size, shape, and mobility of any swelling.
Repeat the examination whilst the patient swallows: ask them to hold a small amount of water in their mouth, then ask them to swallow once your hands are in position.
Consider the consistency of any palpable thyroid tissue: soft = normal, firm = simple goitre, rubbery hard = Hashimoto’s thyroiditis, stony hard = cancer, cystic calcification, fibrosis, Riedel’s thyroiditis.
Feel for a palpable thrill which may be present in metabolically active thyrotoxicosis.

Question 4

Thyroid examination: palpation of the rest of the neck

Answer 4

Palpate the cervical lymph nodes, carotid arteries (to check for patency- can be compressed by a large thyroid), and the trachea for deviation.

Question 5

Thyroid examination: percussion

Answer 5

Percuss downwards from the sternal notch.

In retrosternal enlargement the percussion note over the manubrosternum is dull as opposed to the normal resonance.

Question 6

Thyroid examination: auscultation

Answer 6

Apply the diaphragm of the stethoscope over each lobe of the thyroid gland and auscultate for a bruit.
A soft bruit is indicative of increased blood flow which is characteristic of the hyperthyroid goitre of Graves’ disease.

Question 7

Thyroid examination: skills station model technique- clinically assess this patient’s thyroid status.

Answer 7

Clean your hands.
Introduce yourself.
Explain the purpose of examination, obtain informed consent.
Ask for any painful areas you should avoid.
Observe the patient’s composure (relaxed/ agitated/ fidgety).
Measure the heart rate and note if in AF.
Inspect the hands: erythema, warmth, thyroid acropachy (phalangeal bone overgrowth similar to pulmonary osteopathy).
Feel the palms (sweaty/dry).
Look for peripheral tremor- ask the patient to stretch out their arms with fingers out straight and palms down.
Inspect the face: exophthalmos? proptosis? hypothyroid features?
Examine the eyes.
Examine the thyroid and neck.
Test tendon reflexes at the biceps and ankle.
Test for proximal myopathy by asking the patient to stand from the sitting position.
Look for pretibial myxoedema.
Thank the patient and help them redress as necessary.