Thyroid Examination

Alpar Demeter

The thyroid gland examination or thyroid status examination involves both a peripheral examination of the patient as well as the examination of their thyroid gland. It is important to know signs and symptoms of hypothyroid and hyperthyroid disease. The ability to assess these in a systematic and slick manner is an important skill to learn for your OSCE exams.

Introduction

  1. Wash hands

Wash your hands using the Ayliffe technique

2. Introduce yourself

Introduce yourself and give your name and grade

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“Hi, my name is John Smith and I am a 4th year medical student”

3. Check patient details

Clarify patient's identity by confirming name and asking for their DOB

4. Describe examination

Explain what examination you are performing and what it involves

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“I have been asked to perform a thyroid examination on you today. This involves having a look at your hands and face, and having a feel of your neck”

5. Gain verbal consent

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“Would this be ok with you?”

6. Offer a chaperone

Ask if they would like a chaperone

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“The exam involves you having to remove your upper garment during part of the exam. Would you like a chaperone for this?”

Peripheral Examination

  1. Positioning patient at 45 deg

Lie the patient at 45 degrees and leave them covered

2. End of bed inspection

Inspect the patient from the end of the best and look for the following:

  • Patient - Note fat distribution - thin (hyperthyroid) or overweight (hypothyroid), obvious exophthalmos (hyperthyroid), periorbital myxoedema (hypothyroid)

3. Inspect the hands

Inspect the hands and check for stigmata of chronic GI disease

Skin

Hyperthyroid

  • Smooth, moist warm skin
  • flushed hands
  • Urticaria
  • Vitiligo (Graves disease)

Hypothyroid

  • Cold, dry skin
  • carotenaemia (yellow tinge to skin)
  • eczema craquelé (dermatitis seen in hypothyroidism)

Nails

Hyperthyroid

  • Acropachy (nail overgrowth)
  • Clubbing
  • Onycholysis

Hypothyroid

  • Slow growing brittle nails

Tremor

  • Resting fine tremor seen in hyperthyroidism

4. Check pulse and respiratory rate

Check the patient's pulse and resp rate. Time for 15 seconds and multiply by 4.

  • Tachycardia/tachypnoea (thyrotoxicosis)
  • Irregular (AF) - hyperthyroidism

5. Inspect the face

Next, inspect their eyes and mouth for the following.

Eyes

Thyroid OSCE examination - Face and eye
  • Thyroid eye disease (Graves disease)
  • Exophthalmos (hyperthyroidism)
  • Lid lag (Hyperthyroidism)
  • Conjunctival injection (Hyperthyroidism)
  • Exposure keratopathy (hyperthyroidism)
  • Periorbital myxoedema (hypothyroidism)

Mouth

Large tongue (hypothyroidism)

Hair

  • Smooth hair/ thin (hyperthyroid)
  • Coarse hair/comes out in clumps (hypothyroid)

6. Inspect the legs

Check for pretibial myxoedema (seen in hyperthyroidism).


Neck examination

Thyroid OSCE examination - Neck assessment

Shape

  • Any obvious goitre in the neck that is visible (single nodule or multinodular)

Scar

  • Any signs of a previous thyroidectomy
  • Ask patient to stick their tongue out (thyroglossal cyst will move up)
  • Ask the patient to swallow some water (thyroid gland/thyroglossal cyst will move up)

2. Palpation of the neck

Explain to the patient you will be standing behind them to feel their neck. Palpate for a mass and note the following

  • Size?
  • Location?
  • Tender or not? (Tender - more likely benign, non-tender - more likely malignant)
  • Mobile or not? (Mobile - more likely benign, non-mobile - more likely malignant)
  • Consistency? (Soft and smooth - more likely benign, hard and craggy - more likely malignant)
  • Transilluminates? (fluid filled)
  • Pulsatile? (pulsatile mass likely to be an artery ?aneurysm)
  • Goitre - Palpate for a  goitre and note its consistency and if there are any nodules
  • Ask the patient to sip some water and swallow - does the lump move up? (A thyroid mass will move up)
  • Check for any lymphadenopathy

3. Percussion of the sternum

Percuss down the sternum to hear for any dullness (this may signify a retrosternal goitre)

4. Auscultation of the neck

Auscultate the neck to hear for any bruits - turbulent blood flow through the thyroid gland.


End of examination

  1. Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

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“That’s the end of the exam. Thank you for your time. Would you like any help getting dressed?”

2. State what tests you would perform

Explain to the examiner what tests and investigations you would perform

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ECG
  • Check for arrhythmias
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Bloods tests
  • TFT
  • Anti TPO antibodies
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USS of neck