Video

Geeky Medics - http://geekymedics.com/2010/10/08/thyroid-status-examination/

Exam Summary


1. Introduction

  • Introduce yourself and the examination
  • Sit the patient in a chair
  • Wash your hands

2. Observations

  • Heart Rate
  • Respiratory Rate
  • Temperature
  • Blood Pressure

3. General Inspection

Proptosis.jpg
Proptosis (Exopthalmos) in Grave's Disease

4. Hands

Palmar erythema - redness on the palms of the hands may be due to hyperthyroidism.
Sweat
Onycholysis - separation of nail from nail bed may be due to hyperthyroidism.
Tremor - Ask the patient to lie their hands out, palms up and place a piece of paper on their hands. Tremor is a sign of hyperthyroidism.
Palmar crease pallor - May be due to hypothyroidism related anaemia
Peripheral cyanosis - May be due decreased cardiac output due and limb swelling to hypothyroidism.
palmar_erythema.jpg
Palmar Erythema
Cyanosis.JPG
Peripheral Cyanosis
Onycholysis.jpg
Onychonychia

5. Arms

Radial Pulse - Tachycardia or Atrial Fibrillation in Hyperthyroidism. Bradycardia in Hypothyroidism.
Reflexes - Assess reflexes which may be hyperactive (hyperthyroidism) or hypoactive/ absent (hypothyroidism)

6. Face

a. Eyes

b. Eye movements

Restricted eye movements - make an H-shape with your finger and ask the patient to follow it, looking for restricted eye movements and asking about double vision. This may be due to exopthalmos.

c. Lid Lag

Ask the patient to follow your finger as you move from the top to the bottom of their visual field. If the eyelid drop lags this is due to hyperthyroidism

7. Thyroid Gland

a. Inspection

  • Goitre - is an enlargement of the thyroid gland. 80% of the time the patient is euthyroid, 10% hypothyroid and 10% hyperthyroid.
  • Scars - previous surgery
  • Ask patient to extend their neck
Goitre.jpg
Goitre

b. Swallow

Offer a glass of water.
  • Cancer - Thyroid cancer may not rise or fall when the patient swallows - give the patient water to drink; a goitre or thyroglossal cyst will rise with swallowing

c. Tongue protrusion

  • Thyroglossal cyst - If the mass rises when the patient pokes out their tongue, then the mass is likely to be a thyroglossal cyst. (The thyroid gland originates from the tongue embryologically)

d. Palpation

i. Thyroid

  • Palpation of the thyroid gland is best from behind the patient.
  • Make sure the patient is aware of what is happening.
  • Ask the patient to slightly flex their neck so that the muscles are relaxed.
  • Assess for:
    • size and shape (is it nodular?)
    • consistency (soft = good, hard may suggest carcinoma)
    • tenderness (a sign of thyroiditis)
    • mobility (ask atient to swallow again)
    • thrill (which may occur if the thyroid gland is abnormally metabolically active - hyperthyroidism).
  • Ask the patient to swallow and poke out their tongue again.

ii. Lymph nodes

  • Submental nodes
  • Submandibular nodes
  • Anterior cervical chain
  • Posterior cervical chain
  • Post-auricular
  • Occipital
  • Supraclavicular nodes

iii. Tracheal deviation

  • Warn the patient that this may be uncomfortable. Palpate the trachea above the jugular notch.

e. Percussion

  • Retrosternal goitre - Percuss the upper part of the manubrium to check for a retrosternal goitre.

f. Auscultation

  • Bruit - Listen over each lobe of the thyroid for the presence of a bruit which suggests excessive blood flow to the thyroid in hyperthyroidism.

g. Pemberton's Sign

  • Muscle weakness - Get the patient to stand up and raise their arms above their head, assessing first for proximal muscle weakness due to hyperthyroidism.
  • Retrosternal goitre - ask the patient to keep their arms their for a few minutes. Look at the face for signs of venous congestion or cyanosis which may be due to a retrosternal goitre causing thoracic inlet obstruction.

8. Chest

  • Heart sounds - Listen to the hearts for murmurs which may be caused by hyperthyroidism.

9. Legs

  • Pretibial Myxoedema - Look the tibia for pretibial myxoedema swelling caused by hyperthyroidism despite the name (the name myxoedema can be used to describe severe hypothyroidism).
  • Oedema - Leg swelling that is non-pitting may be caused by hypothyroidism.
  • Reflexes - Assess reflexes which may be hyperactive (hyperthyroidism) or hypoactive/ absent (hypothyroidism)
  • Proximal weakness - test raising from a chair with arms crossed. Weakness in hypothyroidism.
Myxoedema.jpg
Pretibial Myxoedema

10. Conclude

Thank the patient and offer assistance

Citation

Talley and O'Connor - Clinical Examination 7th edition pp355-362
Geeky Medics - Thyroid Status Examination OSCE Guide - http://geekymedics.com/2010/10/08/thyroid-status-examination/
http://geekymedics.com/2010/10/08/thyroid-status-examination/
Proptosis image: "Proptosis and lid retraction from Graves' Disease" by Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center - The Eyes Have It. Licensed under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Proptosis_and_lid_retraction_from_Graves%27_Disease.jpg#/media/File:Proptosis_and_lid_retraction_from_Graves%27_Disease.jpg
Goitre image: "Struma 001" by Drahreg01 - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Struma_001.jpg#/media/File:Struma_001.jpg
"Proptosis and lid retraction from Graves' Disease" by Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center - The Eyes Have It. Licensed under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Proptosis_and_lid_retraction_from_Graves%27_Disease.jpg#/media/File:Proptosis_and_lid_retraction_from_Graves%27_Disease.jpg
Onycholysis image: By CopperKettle (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Myxoedema image: "Myxedema" by Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14924/latest/. Licensed under CC BY 2.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Myxedema.jpg#/media/File:Myxedema.jpg
Palmar erythema image: https://thebileflow.wordpress.com/2012/03/22/pathology-palmar-erythema/
Pretibial Myxoedema image: modified from "Myxedema" by Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14924/latest/. Licensed under CC BY 2.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Myxedema.jpg#/media/File:Myxedema.jpg
Weakness in hypothyroidism.
  • Submental nodes
  • Submandibular nodes
  • Anterior cervical chain
  • Posterior cervical chain
  • Post-auricular
  • Occipital
  • Supraclavicular nodes
.