The thyroid is an endocrine gland located in the neck. It secretes hormones that are responsible for metabolic rate, protein synthesis, and the body’s sensitivities to other hormones.
In this article, we shall look at how to perform an examination of the thyroid gland, and detect signs of thyroid disease.
Introduction
- Introduce yourself to the patient
- Wash your hands
- Briefly explain to the patient what the examination involves
- Ask the patient to sit down on a chair
- Make sure there is sufficient space so you can access the chair from both front and behind
General Examination
- Comment on the patient’s body habitus
- Assess for signs of:
- Obvious alopecia or vitiligo
- Signs of abnormal temperature regulation (sweating or shivering)
- Obvious fine tremor
The Hands
- Inspect the nail beds and fingertips for thyroid acropachy or onycholysis
- Inspect the palms for palmar erythema
- Assess for fine tremor
- Ask the patient to hold hands outstretched with palms facing downwards and place a piece of paper on top of the hands; look for fine movement of the paper
- Feel both hands and assess their temperature
- Palpate the radial pulse
- For both rate and rhythm changes
Adapted from work by CopperKettle, Herbert L. Fred, MD and Hendrik A. van Dijk [CC BY 2.0], via Wikimedia Commons
Fig 1 – Features of thyroid disease in the hands. A) Thyroid acropachy – clubbing and swelling of the digits and toes. B) Onychyolysis – separation of the nail from the nail bed.
The Eyes
- Step behind the patient, tilt the patients head back slightly, and inspect for proptosis (unilateral or bilateral).
- Move to the front of the patient, and inspect the eyes and periorbital area for lid retraction, pale conjunctiva, periorbital oedema, lateral eyebrow loss
- Assess the extra-ocular muscle function
- Instruct the patient to follow your finger in an H shape, keeping their head still
- Ask them to report any double vision
- On downwards movement of the eyes, assess for lid lag
- Assess convergence
- Move your finger in towards the patients nose; ask the patient if this is painful or elicits double vision
By Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center (The Eyes Have It) [CC BY 3.0], via Wikimedia Commons
Fig 2 – Proptosis and lid retraction in thyroid eye disease.
The Face and Head
- Inspect the face for flushing or a ‘peaches and cream’ appearance
- Inspect the head for alopecia or hair thinning
The Neck
- Inspect the neck from the front and the side for
- Size and shape
- Scars from previous surgery
- Ask the patient to take a sip of water and look for movement of the gland
- The gland should move upwards around 1 or 2 fingers with each the swallowing action
- Palpate the thyroid gland
- Positioning yourself behind the patient, start at the midline, move your hands inferiorly to pass over the thyroid cartilage, until you feel the cricoid cartilage and the two inferior tracheal rings (the thyroid and thyroid isthmus overlies this region)
- Using the pads of your fingers, gently pass them over this area to palpate the isthmus and thyroid lobes.
- The thyroid gland is normally palpable in 50% of women, and 25% of men
- Palpate the lymph nodes in the neck
- Submental, submandibular, pre-auricular, anterior cervical, supraclavicular, posterior cervical, post-auricular, and occipital
- Feel for any tracheal deviation
- Percuss down the sternum for any retrosternal dullness
- Retrosternal dullness suggests potential ectopic glandular tissue
- Auscultate the gland; ask the patient to hold their breath and listen for any bruit
The Legs
- Inspect the shins for pretibial myxedema
- Elicit the patellar reflex (assess for any hyper- or hypo-reflexia)
- Perform the sit-to-stand test
- Ask the patient to cross their arms and stand from their chair without using their arms
- Assesses for proximal myopathy
To Complete the Examination
Remember, if you have forgotten something important, you can go back and complete this.
To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to:
- Inspect the chest for signs of gynaecomastia
- Perform a cardiovascular examination (especially for atrial fibrillation or systolic flow murmurs)
- Take a blood pressure reading
