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11/13/24, 7\:10 PM Guide | Thyroid status examination

Thyroid status examination

Table of contents
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Gather equipment

Stethoscope
Glass of water
Tendon hammer
Piece of paper

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Ask the patient to sit on a chair for the assessment.
Adequately expose the patient's neck and upper sternum.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

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Clinical signs

Inspect the patient, looking for clinical signs suggestive of underlying pathology\:
Weight\: weight loss is typically associated with hyperthyroidism (increased metabolism), whilst weight gain is associated
with hypothyroidism (decreased metabolism).
Behaviour\: anxiety and hyperactivity are associated with hyperthyroidism (due to sympathetic overactivity). Hypothyroidism
is more likely to be associated with low mood.
Clothing\: may be inappropriate for the current temperature. Patients with hyperthyroidism su
whilst patients with hypothyroidism experience cold intolerance.
Hoarse voice\: caused by compression of the larynx due to thyroid gland enlargement (e.g. thyroid malignancy).

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Mobility aids\: patients with hyperthyroidism can develop proximal myopathy.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient's recent
medications (e.g. levothyroxine).
Thyroid hormone (T3)
Thyroid hormone (T3) plays an essential role in the normal functioning of cells and therefore excessive or low levels can
cause a broad range of symptoms and clinical signs which can be identi
circulating T3 signi
such as adrenaline resulting in excessive sympathetic output (e.g. tachycardia, tremor, anxiety). Low levels of circulating
T3 have the opposite e
General inspection

Hands

Inspection
Inspect the patient's hands for peripheral stigmata of thyroid-related pathology\:
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Dry skin\: associated with hypothyroidism.
Excessive sweating\: associated with hyperthyroidism.
Thyroid acropachy\: similar in appearance to
secondary to Graves' disease.
Onycholysis\: painless detachment of the nail from the nail bed associated with hyperthyroidism.
Palmar erythema\: reddening of the palms associated with hyperthyroidism, chronic liver disease and pregnancy.
Peripheral tremor
Peripheral tremor is a feature of hyperthyroidism re
To assess for evidence of a subtle peripheral tremor\:
1. Ask the patient to stretch their arms out in front of them.
2. Place a piece of paper across the back of the patient's hands.
3. Observe for evidence of a peripheral tremor (the paper will quiver).
Inspect the hands

Radial pulse

Palpate the patient's radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and
multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
Abnormal heart rates and rhythms
In healthy adults, the pulse should be between 60-100 bpm.
A pulse \<60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals,
hypothyroidism, atrioventricular block, medications, sick sinus syndrome).
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A pulse of >100 bpm is known as tachycardia and also has a wide range of aetiologies (e.g. hyperthyroidism, anxiety,
supraventricular tachycardia, hypovolaemia).
An irregular rhythm is most commonly caused by atrial
Assess pulse rate and rhythm

Face

General inspection

Inspect the patient's face for clinical signs suggestive of thyroid pathology\:
Dry skin\: associated with hypothyroidism.
Excessive sweating\: associated with hyperthyroidism.
Eyebrow loss\: the absence of the outer third of the eyebrows is associated with hypothyroidism (although this is a rare sign).
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Inspect the face

Eyes

Inspect the eyes for evidence of eye pathology associated with thyrotoxicosis (e.g. Graves' disease) including lid retraction,
eye in
Lid retraction
To identify lid retraction inspect the eyes from the front and note if sclera is visible between the upper lid margin and the
corneal limbus (this indicative of lid retraction).
Upper eyelid retraction is the most common ocular sign of Graves' disease however it can be present in other thyrotoxic states
(e.g. toxic multinodular goitre). Eyelid retraction is thought to occur due to sympathetic hyperactivity causing excessive
contraction of the superior tarsal and levator palpebrae superioris muscles.
Exophthalmos
To identify exophthalmos, inspect the eye from the front, the side and from above.
Exophthalmos is bulging of the eye anteriorly out of the orbit. Bilateral exophthalmos develops in Graves' disease, due to
oedema and lymphocytic in
Eye in
Inspect for evidence of in
Due to lid retraction and exophthalmos, the eye is more prone to dryness and the development of conjunctival oedema
(chemosis), conjunctivitis and in severe cases corneal ulceration.
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Inspect the eyes for exophthalmos
Eye movements
Assess for evidence of ophthalmoplegia (e.g. restricted eye movement, diplopia) and pain during eye movement caused by
Graves' disease (lymphocytic in
1. Ask the patient to keep their head still and follow your
2. Move your
3. Observe for restriction of eye movements and ask the patient to report any double vision or pain.
Assess eye movements
Lid lag
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Lid lag refers to a delay in the descent of the upper eyelid in relation to the eyeball when looking downward. Lid lag is most
commonly associated with Graves' disease although it can be present in other thyrotoxic states (e.g. toxic multinodular goitre).
Lid lag is thought to occur secondary to a combination of lid retraction and exophthalmos.
To assess for evidence of lid lag\:
1. Hold your
2. Move your

being visible between the upper lid margin and the corneal limbus.
Assess for lid lag

Thyroid inspection

General inspection

Inspect the midline of the neck from the front and the sides noting any masses (e.g. goitre) or scars (e.g. previous
thyroidectomy). The normal thyroid gland should not be visible.

Further inspection of a mass

If a mass is identi
diagnosis.
Swallowing
Ask the patient to swallow some water and observe the movement of the mass\:
Thyroid gland masses (e.g. a goitre) and thyroglossal cysts typically move upwards with swallowing.
Lymph nodes will typically move very little with swallowing.
An invasive thyroid malignancy may not move with swallowing if tethered to surrounding tissue.
Tongue protrusion
Ask the patient to protrude their tongue\:
Thyroglossal cysts will move upwards noticeably during tongue protrusion.
Thyroid gland masses and lymph nodes will not move during tongue protrusion.
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Inspect the neck

Thyroid palpation

Palpate each of the thyroid's lobes and the isthmus\:
1. Stand behind the patient and ask them to tilt their chin slightly downwards to relax the muscles of the neck to aid palpation
of the thyroid gland.
2. Place the three middle
3. Locate the upper edge of the thyroid cartilage ("Adam's apple") with your
4. Move your
cricoid cartilage and the thyroid isthmus overlies this area.
5. Palpate the thyroid isthmus using the pads of your
6. Palpate each lobe of the thyroid in turn by moving your
7. Ask the patient to swallow some water, whilst you feel for the symmetrical elevation of the thyroid lobes (asymmetrical
elevation may suggest a unilateral thyroid mass).
8. Ask the patient to protrude their tongue (if a mass represents a thyroglossal cyst, you will feel it rise during tongue
protrusion).

Characteristics of the thyroid gland

When palpating the thyroid gland, assess the following characteristics\:
Size\: note if the thyroid gland feels enlarged.
Symmetry\: assess for any evidence of asymmetry between the thyroid lobes (unilateral enlargement may be caused by a
thyroid nodule or malignancy).
Consistency\: assess the consistency of the thyroid gland tissue, noting any irregularities (e.g. a widespread irregular
consistency would be suggestive of a multinodular goitre).
Masses\: note if there are any distinct palpable masses within the thyroid gland's tissue (e.g. solitary thyroid nodule or thyroid
malignancy).
Palpable thrill\: assess for evidence of a palpable thrill caused by increased vascularity of the thyroid gland due to
hyperthyroidism (suggestive of Graves' disease).
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Characteristics of a thyroid mass
If a thyroid mass is noted assess its position, shape, consistency and mobility (i.e. is it tethered to underlying tissue).
Palpate the thyroid cartilage
Thyroglossal cyst
Thyroglossal cysts are the most common congenital abnormality of the neck and arise as a result of the persistence of
the thyroglossal duct. The thyroglossal duct is the tract by which the thyroid gland descends during embryological
development to its
thyroglossal cysts rise during tongue protrusion.
Types of goitre
There are several di
Di
Uninodular goitre\: the presence of a single thyroid nodule which may be active (toxic) autonomously producing
thyroid hormones (causing hyperthyroidism) or inactive.
Multinodular goitre\: the presence of multiple thyroid nodules which may be active or inactive. Active multinodular
goitres are often referred to as a toxic multinodular goitre.

Lymph node palpation

Assess for local lymphadenopathy which may indicate the metastatic spread of primary thyroid malignancy.
1. Position the patient sitting upright and examine from behind if possible. Ask the patient to tilt their chin slightly downwards to
relax the muscles of the neck and aid palpation of lymph nodes. You should also ask them to relax their hands in their lap.
2. Stand behind the patient and use both hands to start palpating the neck.
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3. Use the pads of the second, third and fourth
the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size,
consistency and mobility of lymph nodes.
4. Start in the submental area and progress through the various lymph node chains. Any order of examination can be used, but
a systematic approach will ensure no areas are missed\:
Submental
Submandibular
Pre-auricular
Post-auricular
Super
Deep cervical
Posterior cervical
Supraclavicular
Take caution when examining the anterior cervical chain that you do not compromise cerebral blood
compression). It may be best to examine one side at a time here.
A common mistake is a “piano-playing” or “spider’s legs” technique with the
the pads of the second, third and fourth
Palpate local lymph nodes

Trachea

Inspect for evidence of tracheal deviation, which may be caused by a large goitre.
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Assess for tracheal deviation

Percussion of the sternum

Percuss the sternum moving downwards from the sternal notch to assess for retrosternal dullness.
Retrosternal dullness may indicate a large thyroid mass extending posteroinferiorly to the manubrium.
Assess for retrosternal dullness

Auscultation of the thyroid gland

Auscultate each lobe of the thyroid gland for a bruit using the bell of the stethoscope.
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A bruit indicates increased vascularity, which typically occurs in Graves' disease.
Auscultate each thyroid lobe for a bruit

Further tests

Re

Re
re
Biceps re
antecubital fossa.
1. With the patient’s arm relaxed, locate the biceps brachii tendon which is typically found at the medial aspect of the
2. Place the thumb of your non-dominant hand over the tendon and then tap your thumb with the tendon hammer.
3. Observe for a contraction of the biceps muscle and associated

Pretibial myxoedema

Pretibial myxoedema is a form of di
the dermis and subcutis of the skin. It usually presents itself as a waxy, discoloured induration of the skin on the anterior
aspect of the lower legs (pre-tibial region). Pretibial myxoedema is a rare complication of Graves' disease.

Proximal myopathy

Proximal myopathy is a potential complication of both multinodular goitre and Graves' disease. Patients develop wasting of
their proximal musculature causing di
To screen for proximal myopathy ask the patient to stand from a sitting position with their arms crossed (to minimise their
ability to mask proximal muscle weakness). Make sure to stand close to the patient to prevent them from falling. An inability to
stand up would suggest proximal muscle weakness.
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Assess for hypore

To complete the examination...

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