Thyroid examination

Examination Expected/Normal Comments Potential/Abnormal Comments

Introduction
Hand hygiene
• Cleans hands with alcohol gel
Introduction, explanation and consent ‘Hi, my name is X. I’m a second year
• Introduces self with name and medical student at RCSI. What’s your
level, explains what he/she will be name? Nice to meet you. I’ve been
doing and obtains consent for
asked to examine your thyroid today.
same
That will involve looking and feeling for
any abnormalities in the neck. Would
that be ok?’
Position and exposure ‘Mr/Mrs A is appropriately positioned
• Patient seated and exposed for this examination.’
• Neck and arms exposed
• Legs bare below the knee
Enquires about pain ‘Are you in any pain?’
• Prior to examining
General Inspection – position and exposure
 Patient
Performed from the end of the bed Pretibial Myxoedema (Graves)
 Inspects patient for signs of hyper- ‘On general inspection Mr/Mrs A Tremor (↑)
and hypothyroidism appears well, with normal colour and Sweating (↑)
body habitus, no peripheral stigmata of Obvious neck swelling (↑/↓)
 Equipment thyroid disease and no equipment Scars
around the bed.’ BMI (Low ↑/High ↓)
Colour
 Equipment
o IV drips
o Walking aids
Hands and Arms
• Examines for clubbing & ‘On examination of the hands • Grade X clubbing (↑)
acropachy – done only & arms, there are no stigmata • Acropachy (↑)
though inspection no of thyroid disease evident.’ • Palmar Erythema (↑)
checking for fluctuance • Sweaty Palms (↑)
• Feels palmar surfaces for • Pulse
warmth, erythema and
sweating o Irregular, tachycardia (↑)
• Feels radial pulse & counts o Bradycardia (↓)
heart rate – comment on pulse rate and
rhythm and associated AFib - irregularly • Fine tremor of hands (↑)
irregular • Pemberton’s sign is positive
• Asks patient to hold out o Goitre (↑/↓)
arms, places piece of paper
on hands, observing for fine
tremor which is different
from intention tremor

Thyroid Hand Signs – 6Ps

Face
Eyes
Assesses for signs of eye ‘On examination of the face, Signs of Thyroid Eye Disease
disease by observing the there is no evidence of thyroid • Loss of outer 1/3 of eyebrow (↓)
eye & eyebrows from in eye disease.’ • Periorbital oedema (↑/↓)
front & above patient. • Exophthalmos
• Assesses for lid lag by • Lid retraction
asking the patient to follow • Lid lag Specific to
a finger, moving it along the Graves
 Thyroid examination
arc of a circle from a point • Chemosis
above patient’s head to a • Eyelid swelling /

point below their nose. Need to be done Erythema

quickly
• Assesses extraocular
movements by asking
patient to follow examiner’s
finger in a H pattern asking
if any pain or double vision. Need to do it
slowly

Neck Inspection
Performed from both front and side ‘On closer inspection there is a mass
 Inspects for which…
o Scars – very important. In  Moves upwards with swallowing
thyroidectomy it is a long “On closer inspection there are no
o Thyroid mass
horizontal scar obvious swellings, masses or scars in
the neck”  Moves upwards with tongue
o Masses
o Symmetry protrusion
 Assesses movement of thyroid +/- o Thyroglossal duct cyst
masses on swallowing and tongue
protrusion
 Thyroid gland is just under the
cricoid cartilage which moves
when we swallow
Palpation
‘On palpation of the thyroid there is
In the neck the first buldge is hyoid
cartilage then the biggest one is thyroid  A mass present in the midline
cartilage then cricoid process then is the approximately X x X cm in size
isthmus “On palpation the thyroid gland is which moved upwards on
Then isolate each lobe by pushing to the palpable. It moves upwards with protrusion of the tongue. It was
opposite side and feel for it swallowing. There are no masses or firm/soft/fluctuant with regular
Then ask to swallow and protrude the asymmetries. There is no evidence of well-defined borders and was not
tongue lymphadenopathy” tender or warm.
Comment on heat and border o Thyroglossal duct cyst
Malignant is tethered towards the skin or  A large swelling in the midline. It is
muscle beside it as they infiltrate in so pull smooth with regular borders and is
the skin and move around to see if it approximately Xcm in diameter. It
moves moves upward on swallowing and
Benign is smooth, symmetrical and mobile does not move with protrusion of
the tongue. It is soft/firm/fluctuant
Check for tracheal deviation as thyroid is and not tender or warm.
closely related to it. Comment if it is o Goitre
centralized.  A small nodule in the anterior neck
just lateral to the midline. It is firm
Performed standing behind patient and approximately X x Xcm in size. It
is firm/soft/fluctuant and has
 Palpates both lobes of thyroid regular borders. It is not tender or
with both hands warm and moves upwards with
 Palpates while getting the patient swallowing.
to swallow and stick out tongue o Solitary nodule
 Palpates for cervical and
supraclavicular lymph nodes

Left side of lymph nodes is more

prominent for virchow’s ode is
left supraclavicular node
indicating gastric carcinoma
Right side points more towards
infective causes – pain is felt
 Thyroid examination
Percussion
 Percusses for retrosternal “On percussion of the anterior chest  ‘’On percussion of the anterior
extension – should strike middle there was no evidence of any dullness chest there was evidence of
phalanx of third finger with other which may suggest retrosternal dullness extending to _location_
third finger extension of a thyroid goitre” which is suggestive of retrosternal
extension of a goitre”
Percuss from the angle of Luis up to
sternum to see if it has become a
retrosternal mass. If resonant no
parasternal mass
Auscultation
 Auscultates both lobes of thyroid “On auscultation there were no audible  ‘‘On auscultation there was an
for bruits – which is a hard bruits.’’ audible bruit over the right/left
sound indicating thyroid artery thyroid lobe’’
stenosis or hardening
Thyroid receives supply from IC and
subclavian
For thyroid since it is lower
frequency we will use the bell

Ask the patient to take a deep breath

and hold it to isolate the sound

Additional Tests – Pemberton’s sign indicating SVC obstruction

• Asks patient to hold arms

above head assessing for
facial plethora ideally for
30 sec

o Asks patient elevate both

arms until they touch
sides of face, observes
for facial congestion
and cyanosis, as well as
respiratory distress after
approximately one minute
Lower limb examination
• Observes distal legs for On examination of the • Pretibial myxoedema (Graves) - hyper
swelling & skin changes legs, there are no skin • Proximal myopathy (↓)
(pretibial myxoedema) changes, normal ankle jerks • Hyporeflexia (↓)
• Proximal Myopathy – asks & no evidence of proximal Hyperreflexia (↑)
patient to stand from a myopathy
seated position with arms
crossed.
Checks ankle jerks

Better to check for ankle reflex - Flex the

knee and place over opposite leg
Then dorsiflex and hold the foot and then
hit the achiles tendon

Proximal myopathy – weakness within

muscles is seen in hypothyroidism
Assess power of deltoids – check for
abduction
For lower limb ask to cross hands and
stand up without holding anything

Myoedema seen in front of the shin bone

 Thyroid examination
in Grave’s disease

For hypothyroidism – assess reflex such

as biceps or knee

Please refer to the RCSI clinical handbook if further details are needed.

https://vle.rcsi.com/pluginfile.php/1254232/mod_resource/content/6/RCSI_Handbook_Clinical%20Skills%
20Edition_3rd%20ed_2023.pdf