Thyroid Examination

Thyroid Examination

1. Greet the patient -> handshake
   
   • Handshake
     
     1. Sweating
        
     2. Normal temperature
        
     3. Pulse?
        
2. Explain
   
3. Seek permission
   
4. Right side always
   
5. Proper exposure
   
6. Ensure privacy
   

General Inspection:

• Appropriately dressed for temperature outside?
  
• Comment on obesity, weight loss
  
• Anxious, agitated, lethargic?
  
• Exophthalmos
  
• Dry skin (hypothyroidism)
  
• Hair – loss?
  
• Facial myxedema?
  

Examination of the hands:

• Check pulse (bradycardia, tachycardia, atrial fibrillation)
  
• Check for presence of sweating, increase in temperature, palmar erythema?
  
• Onycholysis (separation of the nail from its bed)
  
• Thyroid acropathy (similar to clubbing)
  
• Ask the patient to extend arms and hold hands with palms facing downwards. Check for fine tremors.
  
  • Rest piece of paper over hands
    
• Elicit Pemberton's sign
  
  • It is the development of facial flushing, distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising of the patient's both arms above his/her head simultaneously, as high as possible.
    

Examination of the thyroid gland:

Inspection:

• Comment on symmetry, scars
  
• Obvious thyroid enlargement?
  
• Midline masses?
  
• Ask the patient to swallow (only goiter or thyroglossal cyst rises upon swallowing)
  
• Protrude the tongue (thyroglossal cyst moves with protrusion of tongue)
  
• Comment on the mass
  
  • The 7 S's (BOX)
    
  • Distention
    
  • Discharge
    
  • Extension
    

Inspection 7 S's

Site (anterior triangle) Size (3x3 cm) Shape (spherical, uniformly enlarged or nodular) Surface (smooth, rubbery, hard) Surrounding skin (normal, ulcers, sinuses) Scars (none) Subcutaneous veins (not)

Palpation:

• Stand behind the patient
  
• Thumbs on back of neck, patient's head slightly flexed
  
• Palpate neck
  
• Ask to swallow and feel the gland move under your fingers (Get below the swelling)
  
• Palpate right lobe
  
  • Turn neck slightly to right
    
  • Ask to swallow
    
  • If palpable, describe size, shape, consistency, tenderness, mobility
    
    • Temperature à surrounding and then on lump
      
    • Tenderness
      
    • Texture
      
    • Trachea
      
  • Repeat for left lobe!
    
• Lymph nodes palpation; also check Virchow's glands
  

Percussion:

• From down upwards; check for retrosternal extension
  
• Also percuss clavicle
  

Auscultation:

• Bruit is a sign of increased blood flow; maybe present in thyrotoxicosis
  
  • Take breath in and hold while auscultating
    
  • Auscultate over two major lobes
    
  • Auscultate with bell
    
    • Also auscultate mitral area
      

Examination of the eyes:

• Lid lag, lid retraction
  
• Chemosis, Proptosis
  
• Exophthalmos (examine from above & behind, from side. Eyes should not be visible beyond the supraorbital ridge)
  
• Check eye movements (ophthalmoplegia); seeing double?
  

Miscellaneous:

• Check reflexes
  
• Proximal myopathy
  
• Pretibial myxedema
  
• CVS examination (failure?)
  
• Internal carotid