Thyroid Gland History and Examination

Question 1

History: What are the 11 key questions to ask in the PC and HPC section of a Thyroid History?

Answer 1

1. Change in Body Weight
2. Change in Appetite
3. Change in voice
4. Change in bowel habits
5. Change in energy level
6. Change in mood
7. Change in concentration
8. Change in heat tolerance
9. Change in skin, hair, nails
10. Change in heart rate/rhythm
11. Change in menstrual cycle

Remember to enquire about the onset and duration of symptoms and any associated pain or
discomfort.
Enquire about previous thyroid disease, surgery or treatment (N.B. Previously hyperthyroid
patients may become hypothyroid after treatment)

Question 2

History: Key drug history questions for thyroid?

Answer 2

Specifically enquire about use of thyroxine, lithium, amiodarone and glucocorticoids

Question 3

History: Key social history for thyroid?

Answer 3

Smoking, alcohol, diet (sufficient iodine?) and effect on activities of daily living

Question 4

History: Key family history for thyroid?

Answer 4

Thyroid disease can be familial

Question 5

Examination: What equipment is needed for a Thyroid Examination?

Answer 5

Glass of water, tendon hammer, stethoscope, sheet of paper

Question 6

Examination: What are the stages of a thyroid examination?

Answer 6

1. Intro
2. Inspection
3. palpation
4. percussion
5. auscultation

Question 7

Examination: Describe the inspection process of the thyroid examination?

Answer 7

Inspect the general appearance of the patient (build, inappropriate clothing,
restlessness, confusion, quality of skin and hair)
• Inspect the hands for thyroid signs:
o Temperature
o Sweating
o Palmar erythema
o Clubbing (thyroid acropachy)
o Brittle nails
o Onycholysis
• Check for a tremor by asking the patient to hold their hands outstretched and pronated
(palms downward). Place a piece of paper on the dorsum of the outstretched hands.
This will amplify a fine tremor.
• Check the patients pulse. Note the presence of bradycardia, tachycardia or atrial
fibrillation.
• Inspect the forearm for muscle wasting
• Inspect the eyes for thyroid signs:
o Inspect for exophthalmos. This is proptosis (forward displacement of the
eye) in association with Graves` disease
o Exophthalmos may lead to inability to close the lids properly. This may
cause sight-threatening exposure keratopathy.
o Inspect for chemosis (conjunctval oedema), conjunctival injection
(“bloodshot” eyes), and periorbital/lid oedema.
o Inspect for lid retraction, which allows the sclera to be seen above the
cornea (sign of all types of hyperthyroidism)
o Inspect for lid lag by asking the patient to look up then down. Delayed
downward movement of the eyelids on downgaze indicates lid lag (sign of
all types of hyperthyroidism).
o Check eye movements in all directions of gaze. There may be a myopathy
of the extraocular muscles. Also, diplopia can result from restricted ocular
mobility, initially involving the inferior rectus muscles
o Check visual acuity and perform fundoscopy. Proptosis may stretch the
optic nerve. The optic disc often appears normal but may be atrophic in
long-standing cases with irreversible loss of vision.
• Inspect the neck for masses.
• Ask the patient to take some water in their mouth then observe the neck while they
swallow it. Does the mass move? If so, this indicates a thyroid mass.
Ask the patient to protrude their tongue (“Stick your tongue out”). Observe the neck.
If the mass moves upwards on tongue protrusion this indicates a thyroglossal cyst.
• Inspect the back of the tongue for a lingual thyroid.

Question 8

Examination: briefly, what are the key areas for inspection?

Answer 8

1. General appearance
2. Hands for signs and tremor
3. pulse
4. forearms for muscle wasting
5. Eyes for thyroid signs
6. Neck for masses
7. Patient swallow water, if mass moves, thyroid mass
8. stick tongue out, if mass moves up, likely thyroglossal cyst
9. Back of tongue for lingual thyroid

Question 9

Examination: Describe the palpation section of the examination?

Answer 9

Palpate the trachea. Is it central?
• From behind, palpate the anterior neck. If there is a mass:
o Determine the size and site.
o Is it diffusely enlarged?
o Is the mass hard or soft on palpation?
o Is the surface smooth or nodular? Is there a single nodule or multiple
nodules?
o Are the surrounding tissues mobile over the mass or is the mass fixed
to the surrounding tissues?
o Can you feel above the mass?
o Can you feel below the mass in the suprasternal notch? If not, it may
be a retrosternal goitre.
o Ask the patient to take some water in their mouth then swallow it, whilst
you are palpating. Does it move on swallowing?
o Ask the patient to protrude their tongue? Does the mass move?
• Palpate the cervical lymph nodes for metastatic spread.

Question 10

Examination: briefly, what are the key areas for palpation?

Answer 10

1. Trachea
2. Anterior neck(from behind)
3. Cervical lymph nodes for metastatic spread

Question 11

Examination: Describe the percussion stage?

Answer 11

Percuss the upper sternum for retrosternal extension of the goitre. (Not obligatory as not useful clinically)

Question 12

Examination: describe the auscultation stage?

Answer 12

Ask the patient to hold their breath. Auscultate with the bell of the stethoscope over the lobes of the thyroid gland for bruits (due to increased blood flow)

Question 13

Examination: What final checks do you do in the thyroid exam after auscultation

Answer 13

• Check for proximal muscle weakness. Ask patient to rise from sitting on a chair whilst folding arms on chest
• Check the ankle reflexes. There may be normally brisk ankle reflexes which are slow to return to the resting state (delayed relaxation) in hypothyroidism.
• Inspect for pretibial myxoedema.