Thyroid examination

Dr Will RickettsClinical Teaching Fellowwith thanks toDr Khalid Malik Thyroid Examination RevisionExamination of Thyroid Basic StructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower limbsCompleting the examination

Introduction - WIPERWASH YOUR HANDS!Introduce yourself & ConsentPosition the patient (seat patient upright with access to examine them from in front and directly behind)Expose the patient (expose the patients neck fully)Retreat....

StructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower limbsCompleting the examinationLook around the bed/chair forMedicationsCardiac monitoring ECGObservations chartWell/unwellAppropriately dressed for room temperature/weatherHot/sweaty or Cold/shiveryComposure (anxious/fidgety/restless or lethargic/immobile)Over/underweightObvious neck lumps/swellingsCondition of hair (dry, thin?)PlethoraEyebrows loss of outer thirdComment on hoarseness of voice

StructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower limbsCompleting the examinationFeel the temperature of the skinLook for:Dry/greasy skinPalmar erythema/sweatingHypercarotenaemia Areas of vitiligoThyroid acropachyOncholysisExamine for Fine TremorCheck Radial PulseStructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower limbsCompleting the examinationBlood Pressure (Ask)*Pembertons Sign*Proximal Myopathy*Reflexes

*Can be done at end as part of completing the examinationStructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower limbsCompleting the examinationFace/HeadPuffy faceThickened skin AlopeciaVitiligo Thin scalp hairGlossitis

StructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower limbsCompleting the examinationEyesInspect for:Loss/thinning of lateral 1/3 eyebrowThyroid stare Lid RetractionPeriorbital oedemaExopthalmos + Complications:Chemosis ConjunctivitisCorneal ulcerationOptic atrophyExamine for:Eye movements/Lid LagVisual Acuity

StructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower limbsCompleting the examination

Thyroid Inspection Inspect from FRONT AND SIDE for:Enlargement of the neck/GoitreScars/Skin ChangesDilated VeinsSwallowThyroglossal Cyst stick out tongue

Goitre Thyroidectomy Scar Thyroid PalpationTracheal DeviationFrom BEHINDPalpate both lobes + isthmus consider:Size Shape (Smooth vs. Irregular)Consistency (Hard vs. compressible)Tenderness (thyroiditis)Mobility SwallowLymph Nodes

Thyroid Percussion The upper part of the manubrium from side to side Change from Resonant Dull = Retrosternal Goitre

Retrosternal ExtensionThyroid Auscultation Listen over each lobe for bruits (Graves or hyperthyroidism)

StructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpate PercussAuscultateLower LimbsCompleting the examinationPre-tibial myxoedemaNon-pitting oedemaProximal MyopathyReflexes

StructureIntroductionInspectionHandsArmsFace and EyesThyroidInspectPalpatePercussAuscultateLower limbsCompleting the examination

Completing the examinationChestInspect for Gynaecomastia Hyperthyroidism Auscultate Heart Look for signs of associated Autoimmune Disease:VitiligoHyperpigmentation, Postural Hypotension AddisonsType 1 Diabetes Malnutrition Coeliac Disease

Thank the patientWASH YOUR HANDS!!

Examination stationsInstructions in the OSCE:Examine this patients THYROID STATUS =complete full thyroid examinationExamine this patients THYROID GLAND = Examine neck/thyroid onlyExamine this patients NECK = Could be As AboveCould be Examination of a NECK LUMPREAD THE INSTRUCTIONS CAREFULLY!!