Thyroid examination

Question 1

Thyroid examination: inspection

Answer 1

Introduction, consent, position patient sitting on a chair with space behind, adequately expose neck.
Inspect from front and sides for any obvious goitres or swellings, scars, signs of hypo/hyperthyroidism.
Is the lump thyroid related or not?
What is the patient’s thyroid status?
Normal thyroid is usually neither visible nor palpable.
Midline swelling should raise suspicion of thyroid pathology.
Look for scars, e.g. collar incision from previous thyroid surgery.
Examine face for signs of hypothyroidism, e.g. puffiness, pallor, dry flaky skin, xanthelasma, corneal Marcus, balding, loss of lateral 1/3 of eyebrow.
Body habitus?
Assess patient’s demeanour- anxious, nervous, agitated, fidgety?- hyperthyroid. Or slow and lethargic?- hypothyroid.

Question 2

Thyroid examination: swallow test

Answer 2

Only goitres, thyroglossal cysts, and sometimes lymph nodes should move up on swallowing.
Standing in front of the patient, ask them to ‘take a sip of water, hold it in your mouth, and swallow’, once neck is visible again, to see if any midline swelling moves up on swallowing.

Question 3

Thyroid examination: tongue protrusion test

Answer 3

Ask patient to ‘stick out your tongue’.

Does the lump move up?- thyroglossal cyst.

Question 4

Thyroid examination: palpation

Answer 4

Stand behind the patient.
The thyroid gland: ask the patient if they’re in any pain. Place middle 3 fingers of either hand along midline below chin and ‘walk down’ to thyroid, 2 finger breadths below the cricoid on both sides. Assess any enlargement/nodules.
Swallow test: repeat as before, now palpating- attempt to ‘get under’ the lump.
Lymph nodes: examine lymph nodes of head and neck.
Trachea: palpate for tracheal deviation from the midline.
If a lump is felt: site, size, shape, smoothness (consistency), surface, surroundings, transirlluminance, fixation/tethering, fluctuance/compressibility, temperature, tenderness, pulsatile.

Question 5

Thyroid examination: face

Answer 5

Eyes: inspect for lid retraction and proptosis (exophthalmos), lid lag and H test, double vision?- ophthalmoplegia of hyperthyroidism.
Proptosis: while standing behind the patient, ask them to tilt their head back slightly- this will give you a better view to assess any proptosis than when assessing the other aspects of eye pathology from the front. Also assess from the sides.
Ask patient to open their mouth wide and say ‘ahh’.
Ask patient to stick their tongue out (moving on to neck).

Question 6

Thyroid examination: percussion

Answer 6

A retrosternal goitre will produce a dull percussion note when the sternum is percussed.

Question 7

Thyroid examination: hands

Answer 7

Inspect for thyroid acropachy (clubbing, seen in Graves’ disease) and palmar erythema (thyrotoxicosis).
Temperature.
Pulse: rate and rhythm, radio-radial delay- tachycardia and AF in hyperthyroid, bradycardia in hypothyroid.
Fine tremor: ask patient to ‘hold hands out’, place sheet of paper over outstretched hands to help- thyrotoxicosis.

Question 8

Thyroid examination: completion

Answer 8

Ask patient to stand up from the chair with arms crossed over chest to assess for proximal myopathy (hypothyroid), look for pretibial myxoedema in the legs (Graves’), test ankle reflexes (or brachial). For ankle reflexes, patient can kneel on chair to make it easier.
Thank patient and wash hands.
Consider whether a lump is goitre, and if it is single/multiple, diffuse/nodular, patient’s thyroid status.

Question 9

Thyroid examination: auscultation

Answer 9

Listen over both lobes of thyroid goitre for bruits- suggests Graves’.