Thyroid status + neck examination Flashcards
What are the parts of a thyroid examination?
- General inspection
- Neck inspection
- Neck palpation
- Palpation of nodes
- Percussion
- Auscultation
- Special tests
- Hands and wrists
- Face
- Limbs
What is part of the general inspection of a thyroid and neck examination?
- Hyperthyroidism -> think, fidgety, tremulous, sweaty, flushed, restless
- Hypothyroidism -> fat, warmly dressed, hair loss, dry skin, deep voice
What is part of the specific inspection of a thyroid and neck examination?
- “Where is the area of concern”
- Look from front and sides; defines locations
- Swallowing (ask patient to take sip of water and hold in mouth, instruct to swallow as you look from front. Look from other angles)
- Stick out tongue
What is part of the palpation of the neck of a thyroid and neck examination?
“Do you have any pain the neck”
- Start behind the patient and use both hands to examine the lump, or feel for swelling if that’s the concern
- Palpate from behind when patient swallows water
- Attempt to transilluminate lump
What parameters would you consider when examining the lump?
- Size/shape/symmetry
- Surface
- Consistency
- Edge
- Fluctuance (e.g. lipoma)
- Pulsation
- Temperature
What are Graves’ lumps like?
Soft, smooth and symmetrical
What are multinodular lumps like?
Firm, nodular, asymmetrical
How would you describe the edge of a lump?
Well defined, indistinct, irregular
What can pulsation of a lump imply?
Carotid body tumour
Why is the temperature of a lump important?
Increased warmth may suggest an inflammatory or infective cause (e.g. infected epidermoid cyst)
How would you assess thyroid swelling?
- Diffuse enlargement or single nodule?
- If diffuse, is it smooth or multi nodular?
- Lower extent - can you get below the thyroid?
What is part of the percussion of the neck of a thyroid and neck examination?
Both sides of the lump
A retrosternal goitre may cause a dull percussion note
What is part of the auscultation of the neck of a thyroid and neck examination?
Both sides of the lump while patient holds their breath
Why is auscultation important in a neck exam?
Bruits are virtually diagnostic of Graves’!
What is part of the special tests that can be performed in a thyroid and neck examination?
Pemberton’s test (if large goitre): raise both hands above head and take slow breath in
Listen for stridor which is indicative of tracheal compression
What is part of the hands and wrist assessment of a thyroid and neck examination?
Clubbing Palms Palmar erythema Paper (put on hands to detect fine tremor) Pulse
What can you see in hypo versus hyperthyroidism in the following:
Clubbing Palms Palmar erythema Paper (put on hands to detect fine tremor) Pulse
Clubbing: a sign of Graves; none for hypo
Palms: hot and sweaty in hyper, cold and dry in hypo
Palmar erythema: yes in hyper, no in hypo
Tremor: yes in hyper, no in hypo
Pulse: tachycardia and AF in hyper, bradycardia in hypo
What is part of the face assessment of a thyroid and neck examination?
Facial appearance Hair and eyebrows Eyes Eye movement Lid lag
What can you see in hypo versus hyperthyroidism in the following:
Facial appearance Hair and eyebrows Eyes Eye movement Lid lag
Facial appearance: flushed in hyper, peaches and cream in hypo
Hair and eyebrows: thin and brittle in hypo
Eyes: exophthalmos in Graves! Eyelids may be retracted in hyper, and may be puffy in hypo
Eye movement (H movement): ophthalmoplegia (upwards gaze) in Graves’
Lid lag (move finger upwards, then downwards quickly): present in hyper
What is part of the limbs assessment of a thyroid and neck examination?
- Knee and biceps reflexes
- Carpal tunnel syndrome (median nerve power and sensation, Tinel/Pathen tests)
- Proximal myopathy (shoulder abduction, stand up with arms crossed)
- Oedema (pre-tibial myxoedema, generalised non-pitting peripheral oedema)
What can you see in hypo versus hyperthyroidism in the following:
- Knee and biceps reflexes
- Carpal tunnel syndrome (median nerve power and sensation, Tinel/Pathen tests)
- Proximal myopathy
- Oedema
- Knee and biceps reflexes: brisk in hyper, slow-relaxing in hypo
- Carpal tunnel syndrome: common in hypo
- Proximal myopathy: yes in hyper
- Oedema: myxoedema in Graves’, pitting oedema in hypo
What would you suggest after a thyroid and neck examination?
TFTs, USS, FNA
What are the different types of lumps based on the location:
- Midline
- Anterior triangle
- Posterior triangle
- Anywhere
- Midline: goitre, thyroglossal cyst
- Anterior triangle: branchial cyst, carotid body tumour, lymph node
- Posterior triangle: cystic hygroma, lymph node
- Anywhere: lipoma, sebaceous cyst
What are causes of a goitre?
- Multinodular goitre
- Graves’ disease
- Solitary nodule
- Hashimoto’s thyroiditis
- Subacute thyroiditis
