Thyroid examination signs Flashcards
What clinical signs are you looking for on general inspection?
Weight
- weight loss: hyperthyroidism (increased metabolism)
- weight gain: hypothyroidism
Behaviour
- anxiety and hyperactivity are associated with hyperthyroidism (due to sympathetic overactivity)
- hypothyroidism is more likely to be associated with low mood
Clothing
- ? appropriate for current temp.
- hyperthyroidism = heat intolerance
- hypothyroidism = cold intolerance
Hoarse voice
- caused by compression of the larynx due to thyroid gland enlargement (e.g. thyroid malignancy)
What objects and equipment are you looking for?
Mobility aids (patients with hyperthyroidism can develop proximal myopathy) and prescriptions
What signs are you looking for when inspecting the hands?
- Thyroid acropachy - similar in appearance to finger clubbing but caused by periosteal bone overgrowth secondary to Graves’ disease
- Onycholysis: painless detachment of the nail from the nail bed associated with hyperthyroidism
- Palmar erythema: reddening of the palms associated with hyperthyroidism, chronic liver disease and pregnancy.
What is a peripheral tremor a feature of?
Hyperthyroidism reflecting sympathetic nervous system overactivity
What can a change in pulse rate indicate?
Increased = hyperthyroidism Decreased = hypothyroidism
What signs are you looking for in a general inspection of the face?
- Dry skin: hypothyroidism
- Excessive sweating: hyperthyroidism
- Eyebrow loss: the absence of the outer third of the eyebrows is associated with hypothyroidism (rare though)
What signs in the eyes are associated with thyrotoxicosis (e.g. Graves’ disease)
- lid retraction
- eye inflammation
- exophthalmos (AKA proptosis)
- eye movement abnormalities
- lid lag
Why does bilateral exophthalmos develop in Graves’ disease?
Oedema, lymphocytic infiltration of orbital fat, connective tissue and extraocular muscles
Due to lid retraction and exophthalmos, the eye is more prone to what?
More prone to dryness and the development of conjunctival oedema (chemosis), conjunctivitis and in severe cases corneal ulceration.
What signs in eye movements are you looking for?
Ophthalmoplegia (e.g. restricted eye movement, diplopia) and pain during eye movement caused by Graves’ disease (lymphocytic infiltration of orbital fat, connective tissue and extraocular muscles
What does lid lag refer to?
Delay in the descent of the upper eyelid in relation to the eyeball when looking downward.
What is lid lag most commonly associated with?
Graves’ disease although it can be present in other thyrotoxic states (e.g. toxic multinodular goitre). Lig lag is thought to occur secondary to a combination of lid retraction and exophthalmos.
What signs are you checking for when carrying out a general inspection of the thyroid gland?
- noting any masses (e.g. goitre)
- scars (e.g. previous thyroidectomy)
- the normal thyroid gland should not be visible
What are the characteristics of masses when the patient swallows water?
- thyroid gland masses (e.g. a goitre) and thyroglossal cysts typically move upwards with swallowing
- lymph nodes will typically move very little with swallowing
- an invasive thyroid malignancy may not move with swallowing if tethered to surrounding tissue.
What will protrusion of the tongue potentially show for
- thyroglossal cysts
- thyroid gland masses and lymph nodes
- thyroglossal cysts will move upwards noticeably during tongue protrusion
- thyroid gland masses and lymph nodes will not move during tongue protrusion.
When inspecting the neck what signs are you looking for?
Skin changes - erythema
Scars - thyroidectomy
Masses - goitre/ lymph node
What characteristics are you assessing when palpating the thyroid gland?
- size
- symmetry (? asymmetry between the thyroid lobes): unilateral enlargement may be caused by a thyroid nodule or malignancy)
- consistency e.g. a widespread irregular consistency would be suggestive of a multinodular goitre
- masses e.g. solitary thyroid nodule or thyroid malignancy
- palpable thrill e.g. caused by increased vascularity of the thyroid gland due to hyperthyroidism (suggestive of Graves’ disease)
If a thyroid mass is noted what should you assess?
position, shape, consistency and mobility (i.e. is it tethered to underlying tissue)
Explain about a thyroglossal cyst
- congenital abnormality 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 embyrological 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.
What are the 3 different subtypes of goitre?
- diffuse goitre
- uninodular goitre
- multinodular goitre
What is a diffuse goitre?
the whole thyroid gland is enlarged due to hyperplasia of the thyroid tissue
What is a uninodular goitre?
The presence of a single thyroid nodule which may be active (toxic) autonomously producing thyroid hormones (causing hyperthyroidism) or inactive)
What is a multinodular goitre?
The presence of multiple thyroid nodules which may be active or inactive. Active multinodular goitres are often referred to as a toxic multinodular goitre.
What can local lymphadenopathy indicate?
Metastatic spread of primary thyroid malignancy
Percussion of the sternum: what may retrosternal dullness indicate?
Large thyroid mass extending posteroinferiorly to the manubrium
What does a bruit indicate?
Increased vascularity, which typically occurs in Graves’ disease
What are the reflexes assessed to screen for?
Hyporeflexia - which is associated with hypothyroidism
What is pretibial myxoedema?
It is a form of diffuse mucinosis in which there is an accumulation of excess glycoasminoglycans in the dermis and subcutis of the skin.
How does pretibial myxoedema usually present?
Waxy, discoloured induration of the skin on the anterior aspect of the lower legs (pre-tibial region).
What is pretibial myxoedema a rare complication of?
Graves’ disease
What is proximal myopathy a potential complication of?
Both multinodular goitre and Graves’ disease
What happens in proximal myopathy?
Patients develop wasting of their proximal musculature causing difficulties in tasks such as standing from a sitting position
