Makindo Medical Notes

Related Subjects: |Thyrotoxicosis and Hyperthyroidism |Thyroid Storm - Thyrotoxic crisis |Graves Disease (Thyrotoxicosis) |Amiodarone and Thyroid disease |Thyroid Surgery (Thyroidectomy) |Hypothyroidism |Hashimoto's thyroiditis |DeQuervain's thyroiditis |Subacute Thyroiditis |Thyroid nodule |Congenital Hypothyroidism |Thyroid Function Tests and antibodies |Post partum thyroiditis |Sick Euthyroid Syndrome |Thyroid Exam (OSCE) |Thyroid Gland anatomy and Physiology |Thyroid Cancer

When asked to examine the thyroid try and establish clues to thyroid status - ither hypothyroid, euthyroid or hyperthyroid and show that you have considered it as well. Always be ready to look for single nodules that could indicate malignancy

Equipment

• Stethoscope
• Piece of paper
• Glass of water
• Tendon hammer

Review anatomy

Introduction (Use the acronym WIPER to prepare for the examination)

• W - Wash your hands
• I - Introduce yourself and confirm patient details
• P - Permission - gain consent to proceed with the examination, including explaining relevant details
• E - Expose the patient appropriately, gather Equipment
• R - Reposition the patient

Inspection: Look for clues to thyroid status

Background Information for Assessing Thyroid Status

• The patient will usually be seated in a chair for the assessment so that you can examine form behind and above
• Ensure you have exposed the patient’s neck and upper chest and ensure that the patient is comfortable at rest
• Listen for any stridor which may suggest tracheal obstruction
• Look at the patient and try to work out if they be hyperthyroid or hypothyroid.
• Most patients in exams will have treated disease but eye signs and goitre and nodules can persist
• Thyroid status
  • Hyperthyroid
    • Slim build under usual weight
    • Sweaty feeling warm with minimal clothing (heat intolerance)
    • Agitated and tremulous
  • Hypothyroid
    • May be over their usual weight and Feeling cold so overdressed (cold intolerance)
    • Low mood, flat affect, depressed, confusion, lethargy
    • Hoarse voice tends to suggest underactive thyroid
• Voice: hoarseness may indicate a large goitre compressing the larynx or laryngeal nerves.
• Slow and slurred speech indicates hypothyroidism.

Hands

• Look at the hands, Palate the radial pulse, assessing rate and rhythm.
• Thyroid status
  • Hyperthyroid
    • Tachycardia, warm and sweaty erythematous palms
    • Tremor: a fine tremor due to excess sympathetic drive may be immediately apparent. Some place a piece of paper on the back of outstretched hands to detect the tremor.
    • Atrial fibrillation is an excellent finding and good toe mention presence or absence
    • Underdressed (heat intolerance)
    • Anxious, Agitated and tremulous
    • Thyroid acropachy - digit swelling and clubbing seen with Grave’s disease
    • Onycholysis - separation of the nail from the nail bed. Seen with Grave’s disease
  • Hypothyroid
    • Bradycardia
    • Carpal tunnel syndrome from myxoedema

Thyroid Hand signs

Face and Eyes

Eye pathology with thyroid disease is typically associated with Grave’s disease.

• Hypothyroid
  • Dry puffy skin and loss of outer third of eye brow
  • Diffuse hair loss may be seen
  • Periorbital oedema
• Hyperthyroid
  • Sweaty, with a flushed face and warm
  • Lid retraction and lag due to overstimulation of Mullers muscle
• Eyes: Inspect the eyes from the front, side, and from above.
  • Grave's disease
    • Exophthalmos
    • Eye inflammation, presenting as conjunctival chemosis.
  • Test Eye movements
    • Follow your finger with their eyes without moving their head.
    • Use an H-shaped movement to look for any ophthalmoplegia and diplopia
    • Assess for lid lag simultaneously due to sympathetic stimulation to Mullers muscle.

Thyroid eye signs

Examining the thyroid and neck

Assess lymph nodes using the pads of the fingers, rolling in circles through each lymph node area. Avoid ‘piano playing’ as this is likely to miss an enlarged node.

• Inspection from the front of the patient and then move behind to inspect from above and then palpate
  • The thyroid is located in the midline of the neck.
  • A normal thyroid is not usually visible.
  • A thyroidectomy scar is a semilunar or horizontal line at the base of the neck
  • A goitre may be visible as a symmetrical or asymmetrical neck swelling.
  • If a mass is detected, assess its movements on swallowing a sip of water and tongue protrusion
  • Swallowing - ask patient to take a sip and hold it and then swallow when instructed
    • Goitre and any thyroid mass moves up
    • Thyroglossal cyst moves up
    • Lymph nodes do not move up
  • Tongue protrusion
    • Thyroglossal cysts move up
    • thyroid masses and nodes do not move up
• Palpation
  • Stand behind the patient so that you can palpate the neck of the seated patient from patient.
  • Palpate below the thyroid cartilage until you reach the cricoid cartilage. Below this lies the isthmus of the thyroid gland
  • Note the size of the gland - enlargement indicates a goitre, which can be symmetrical swelling or asymmetrical enlargement relating to a distinct nodule or mass
  • Tender: Thyroiditis
  • Assessing a Goitre: Consistency, size
    • Smooth, uniform enlargement with no nodules is a diffuse goitre
      • Grave’s disease: Soft and may have bruit.
      • Hashimoto’s thyroiditis
      • Endemic goiter
    • Firm
      • Hashimoto’s thyroiditis
      • Malignancy
      • Benign and malignant nodules.
    • Irregular consistency indicates a multinodular goitre.
    • Nodules may be solid or cystic.
      • Simple Cyst
      • Multinodular Goiter
        • Iodine deficiency
      • Benign tumour
      • Malignant tumour
        • Hardness, rapid growth
        • Fixed to surrounding tissue
        • Localised lymphadenopathy
        • Ask about radiation exposure
      • Note the position, size, and shape, of any mass, tethering to underlying tissues or fluctuance.
    • Examine for localised Lymph nodes
      • Check submandibular, cervical, and supraclavicular nodes
      • Check if hard, mobile, tender, size
    • Examine the Trachea
      • Assess for tracheal deviation by placing the fingers horizontal to the suprasternal notch and palpating into the neck on either side of the trachea.
      • Deviation can occur with a large goitre.
      • Stridor can occur with a large goitre compressing trachea
• Percussion of the thyroid
  • Percuss downwards from the sternal notch to assess for retrosternal dullness
  • This may indicate a large goitre extending posteroinferiorly into the mediastinum
• Auscultation
  • Auscultate each lobe of the thyroid gland for bruits
  • A continuous audible turbulence that can occur due to increased vascularity of an enlarged thyroid gland.

Further tests

• Test the biceps or knee jerk reflex as Hyporeflexia is associated with hypothyroidism
• Pretibial myxoedema is an infiltrative dermopathy that can occur in Grave’s disease, presenting with waxy discolouration and induration of the skin in the lower legs
• Proximal myopathy may occur in Grave’s disease, presenting with difficulty standing from seating with the arms crossed.

Completing the examination

• Thanks the patient and Wash your hands
• Summarise your thoughts and present your findings
• Further tests can include ECG, TFTs and Thyroid imaging.