Thyroid Examination

Question 1

4 pieces of equipment needed?

Answer 1

Stethoscope
Glass of water
Tendon hammer
Piece of paper

Question 2

General inspection - Clinical signs:

Why do you look at weight?

Why do you look behaviour?

Why do you look at clothing?

What does a hoarse voice indicate?

Answer 2

Weight loss - hypo
Weight gain - hyper

Anxiety and hyperactivity - hyper
Depression - hypo

May be inappropriate for the current temperature.

Heat intolerance - hyper
Cold intolerance - hypo

Compression of the larynx or the nerve supplying it

Question 3

General inspection - Objects and equipment:

Why do you look for mobility aids in hyperthyroidism?

Answer 3

They can develop proximal myopathy

Question 4

Hands - Inspection:

What does the following suggest?

• Dry skin
• Excessive sweating
• Thyroid acropachy
• Oncycholysis
• Palmar erythema

Answer 4

Associated with hypothyroidism

Hypo
Hyper
Graves disease

Hyper - painfless detachment of the nail from the nail bed

Hyper, CLD and pregnancy

Question 5

Hands - peripheral tremor:

What does tremor suggest?

How can this be tested?

Answer 5

Hyper

1. Ask the patient to stretch their arms out in front of them.
2. Place a piece of paper across the back of the patient’s hands.
3. Observe for evidence of a peripheral tremor (the paper will quiver).

Question 6

Hands - Radial pulse:

How long should you measure the pulse for if irregular rhythm?

What is it associated with?

What does bradycardia suggest?

What does tachycardia suggest?

Answer 6

60 seconds

Hyper - AF

Hypo

Hyper

Question 7

Face - General inspection:

What does the following suggest?

• Dry skin
• Excessive sweating
• Eyebrow loss

Answer 7

Hypo

Hyper

Hypothyroidism - they loss the outer third of their eyebrows - though this is rare

Question 8

Eyes - inspection:

How do you look for lid retraction? Why does it occur?

How do you look or exophthalmos?

Why should you check the eye for inflammation?

Answer 8

If the sclera is visible above and below the iris

(Due to sympathetic hyperactivity causing excessive contraction of the superior tarsal and levator palpebrae superioris muscles).

Inspecting the eye from the front, the side and from above.

Due to lid retraction and exophthalmos, the eye is more prone to dryness and the development of conjunctival oedema (chemosis), conjunctivitis and in severe cases corneal ulceration.

Question 9

Eyes - Tests:

Why do you test eye movements?

How do you test eye movements?

Answer 9

Ophthalmoplegia causes restricted eye movement, diplopia and pain during eye movement caused by Graves’ disease (lymphocytic infiltration of orbital fat, connective tissue and extraocular muscles)

H test - ask patient to report any double vision

Question 10

Eyes - Tests:

How do you know if a patient has lid lag if you ask them to follow your finger downwards?

Answer 10

If lid lag is present, the upper eyelids will be observed lagging behind the eyes’ downward movement, with the sclera being visible between the upper lid margin and the corneal limbus.

Question 11

Thyroid inspection:

Is the thyroid gland usually visible?

(1) Swallowing some water:
- What direction will a thyroid gland mass and thryoglossbal cyst move?

(2) Tongue protrusion:
- What direction will a thyroid gland mass move?
- What direction will a thryoglossbal cyst move?

Answer 11

Upwards with swallowing

No

Moves upwards

Doesn’t move at all

Question 12

Thyroid palpation:

What can you get the patient to do to help distinguish between a cyst and a thyroid mass?

What does the wide spread irregularity of the thyroid suggest?

What does a palpable thrill suggest?

Where do you start palpation from?

Answer 12

Swallowing and tongue protrusion

Multinodular goitre

Graves diseases due to increased vascularity of the thyroid

Thyroid cartilage (“Adam’s apple”) with your fingers.

Move your fingers inferiorly until you reach the cricoid cartilage.

Question 13

Thyroid palpation:

Why do thryoglossbal cysts rise during tongue protrusion?

Answer 13

Thyroglossal cysts are the most common congenital abnormality of the neck and arise as a result of the persistence of the thyroglossal duct. The thyroglossal duct is the tract by which the thyroid gland descends during embryological development to its final position in the front of the neck. The tongue is attached to the thyroglossal duct, which is why thyroglossal cysts rise during tongue protrusion.

Question 14

Lymph node palpation:

What does enlargement indicate?

Answer 14

Assess for local lymphadenopathy which may indicate the metastatic spread of primary thyroid malignancy

Question 15

Trachea:

What may a large goitre cause?

Answer 15

Deviation

Question 16

Percussion of the sternum:

Why?

Answer 16

To assess for retrosternal dullness.

Retrosternal dullness may indicate a large thyroid mass extending posteroinferiorly to the manubrium.

Question 17

Ausculation of the thyroid gland:

Why?

Bell/diaphragm of stethoscope?

Answer 17

A bruit indicates increased vascularity, which typically occurs in Graves’ disease.

Bell

Question 18

Further tests:

Reflexes are tested. Why?

What may be seen on the legs in graves disease?

Proximal myopathy is a potential complication of both multinodular goitre and Graves’ disease. Patients develop wasting of their proximal musculature causing difficulties in tasks such as standing from a sitting position.

How do test for this?

Answer 18

Reflexes are assessed to screen for hyporeflexia, which is associated with hypothyroidism.

Pretibial myxoedema

Ask the patient to stand from a sitting position with their arms crossed (to minimise their ability to mask proximal muscle weakness). Make sure to stand close to the patient to prevent them from falling. An inability to stand up would suggest proximal muscle weakness.