Examination of the Thyroid

Ask for consent and then continue with inspection

“Is there any pain at all? (response) and would it be alright if, while i am examining you, that i speak to the examiner about you?"

(remember to wait for response - too often we rehearse these examinations so often that we forget to wait for the answers to these questions in the panic of an exam)

Expose the neck to below the clavicles

“Firstly on general inspection – there is no obvious restlessness, anxiety, sweating, vitiligo and the patient is dressed appropriately for the temperature of the room.” “Moving on to the hands"
"There are no signs of thyroid acropachy (thyroid clubbing), onycholysis, or tremor"
turn hands over
"No increased sweating or palmar erythema in the palms. The pulse appears to be regular (AF) with a heart rate which is within normal limits”

Eyes

• Loss of hair from outer 1/3 of eyebrows
• Lid retraction – elevation of upper eyelid
• Exophthalmos (sclera is seen all the way round the pupil) – due to retro-orbital inflammation and lymphocytic infiltration oedema and pushes the eye forward (proptosis)
• Chemosis – venous and lymphatic drainage is disturbed by the protrusion of the eye and the appearance is oedematous and wrinkled
• Lid lag – follow a finger slowly from up to down to see if the upper eye lid is left behind. (sympathetic ­stimulation and restrictive myopathy of levator palpebrae superioris) Opthalmoplegia - paralysis of ocular muscles
• Proptosis – protruding eye beyond the level of the supra-orbital ridge

Neck Examination

“On inspection there are no obvious lumps, scars, or raised jugular venous pulse (neck vein obstruction).”
“Stick out your tongue (assess for any lump movement in midline).”
“Now would you please take a sip of water in your mouth but don’t swallow it until I say ‘go’.” (once the patient has taken a sip ask them to extend his/her neck a bit until you can clearly see the neck and then ask them to swallow. Without this break the swallow action occurs with the glass of water obscuring your view.)

Ask the patient to count to 10 – to assess for hoarseness.

Palpation
Again ask if there would be any pain if you were to touch the patient. Stand behind the patient and examine with the pulps of your fingers.

• Describe as for any lump (please see Lump Examination if you require more help with this.) as a minimum you should make sure you say if the lump is diffuse, nodular (multiple) or solitary nodule.
• Repeat the ‘Stick out tongue’ and ‘swallow test’.
• Check for trachea deviation
• Cervical lymphadenopathy

Percuss over the sternum for retro-sternal extension.

You can now attempt to wrap up the examination with some final examination that they may or may not ask you to do.

"I would then check for slowly relaxing reflexes (ankle), pre-tibial myxoedema, and proximal myopathy (upper arm).
"I would also take a thyroid status history"

• Do you prefer a warm or cold room?
• Have you lost or gained any weight recently?
• How is your appetite?
• How is your bowel habit?
• Are you more anxious or more depressed than before?
• Have you suffered from palpitations or chest pain / angina?
• Have your periods changed?
• Have you been treated for diabetes or anaemia or any other autoimmune diseases?
• Are you on any medication?
• Have you ever had an operation or radiotherapy on your thyroid?

"I would then examine this patient’s vocal cords with a flexible fibreoptic nasoendoscope to assess for any palsy."

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