2. HISTORY
1. AGE:
• It is a very important consideration.
• Simple goiter is commonly seen in girls approaching puberty.
• In endemic areas deficient iodide is the cause of simple goiter.
• Both multinodular and solitary nodular goiters as well as colloid
goiters are found in women of 20s and 30s.
• Papillary carcinoma is seen in young girls and follicular carcinoma in
middle aged women.
• Anaplastic carcinoma is mainstay a disease of old age.
3. 2. SEX:
• Majority of thyroid disorders are seen in females
• All types of simple goiters are far more common in
females than in males.
• Thyrotoxicosis is 8X more common in females than in
males.
• Even thyroid carcinomas are more often seen in
females in the ratio 3 : 1
4. 3. OCCUPATION:
•Though occupation has hardly any relation with
thyroid disorders, yet thyrotoxicosis may appear
in individuals working under stress and strain.
•The patients with primary toxic goiter may be
psychic.
5. 4. RESIDENCE:
• Expect endemic goiter due to iodine deficiency
• No other thyroid goiter has any peculiar geographical
distribution
• Certain areas are particularly known to have low
iodine content in water and food. Residence of these
areas often suffer from iodine deficiency endemic
goiter. These areas are near rocky mountains.
6. 5. SWELLING:
• In case of thyroid swelling history about onset, duration, rate of
growth and whether associated with pain should be noted.
• In case of any thyroid swelling it should be asked how the patient
sleep at night.
• Does she spend sleepless night??
• In primary thyrotoxicosis patients often complain of sleepless night.
• Whether the patient is very worried, stressed or strained are also feature of
thyrotoxicosis.
• Palpitations, ectopic beats and even CCF may be noted in cases of
secondary thyrotoxicosis.
7. • In secondary thyrotoxicosis the brunt of the attack fall more on
cardiovascular system, whereas the primary thyrotoxicosis the brunt
of the attack fall more on nervous system.
• Sudden increase in size with pain in a goiter indicates haemorrhage
inside.
• The rate of growth of swelling is quite important.
• While simple goiter grows very slowly or may remain the same size for quite
some time, multinodular, solitary nodular or colloid goiters increase in size
though extremely slowly for year.
• A special feature of papillary and follicular carcinoma of the thyroid is their
slow growth.
• They may exist as a lump in the neck for many years before metastasing
• Anaplastic carcinoma however is a fast growing swelling
8. 6. PAIN
• Goiter is usually painless condition.
• Inflammatory conditions of the thyroid gland are painful.
• Malignant diseases of the thyroid gland are painless to start
with, but become painful in late stages.
• In Hashimoto’s disease there is discomfort in the neck.
• Anaplastic carcinoma is more known to infiltrate the
surrounding structures and nerves to cause pain.
9. 7. PRESSURE EFFECTS:
•Enlarged thyroid may press on the
•trachea to cause dyspnoea
•Esophagus to cause dysphagia
•Recurrent laryngeal nerve to cause
hoarseness of voice
10. 8. SYMPTOMS OF PRIMARY THYROTOXICOSIS
• It is very important to understand the symptoms primary
thyrotoxicosis as often on these cases there is not much enlargement
of the thyroid gland and only these symptoms will indicate the
presence of this disease.
• Loss of weight (the most significant symptom)
• Preference to cold, intolerance to heat and excessive sweating are the next
symptoms.
• Nervous excitability, irritability, insomnia, tremor of hands and weakness of
muscles are the symptoms of involvement of CNS which are the main features
of primary thyrotoxicosis.
• Cardiovascular symptoms are not so pronounced as seen in secondary
thyrotoxicosis, but even then palpitation, tachycardia and dyspnoea on
exertion are symptoms of this disease.
11. • Exophthalmos is often associated with this condition.
• The patient may complain of staring or protruding eyes and
difficulty in closing her eye lids.
• Double vision (diplopia) may be caused by muscle weakness
(Ophthalmoplegia)
• Edema or swelling of the conjunctiva (chemosis) is seen in very
late cases of exophthalmos.
• Ultimately the patient may get pain in the eye if the cornea
ulcerates
• Some women may have change in menstruation, usually
amenorrhea.
12. 9. SYMPTOMS OF SECONDARY THYROTOXICOSIS:
• When a long standing solitary nodular, multinodular or colloid goiters
shows manifestations of thyrotoxicosis, the condition is called
secondary thyrotoxicosis.
• As explained above the brunt of the attack falls more on the
cardiovascular system than on the nervous system.
• Palpitations, ectopic beats, cardiac arrhythmias, dyspnoea on exertion
dyspnoea on exertion and chest pain are the usual symptoms.
symptoms.
• Even CCF may appear at late stage with swelling of ankles.
• Nervous symptoms and eye symptoms may be mild or absent.
13. 10.SYMPTOMS OF MYXOEDEMA (HYPOTHYROIDSM)
• Increase in weight is often complained inspite of poor appetite.
• Fat accumulates particularly at the back of the neck and shoulders.
• Intolerance of cold weather and preference of warm climate is noticed.
• There is minimal swelling of the thyroid.
• The skin may be dry
• There may be puffiness of the face with pouting lips and dull expression.
• Loss of hair is a characteristic feature and 2/3rd of he eyebrows ,may fall off.
off.
• Muscle fatigue and lethargy are important symptoms with failing memory and
memory and mild hoarseness due to edema of vocal cords.
• Constipation and oligomenorrhea are sometimes complained of.
14. 11.PAST HISORY:
•Enquiries must be made about the course of
treatment the patient had and its effect on
the swelling.
•The patient should also be asked if she was
taking any drugs e.g. sulphoniuria or any
Antithyroid drugs as these are goitrogenic.
15. 12.PERSONAL HISTORY:
•Dietary habit is important as vegetables of the
brassica family (cabbage, kale and rape) are
goitrogens.
•Persons who are in the habit of taking a kind of
sea fish which has particularly low iodine
content, may present with goiter.
16. 13.FAMILY AND SOCIAL HISTORY:
• It is often seen that goiters occur in more than one member
in a family while endemic goiters may affect more members
in the same family.
• Similarly enzyme deficiencies within the thyroid gland which
are concerned in the synthesis of thyroid hormones are also
seen to run in families.
• Primary thyrotoxicosis has been seen in more than one
member of the same family.
• Thyroid cancers are seen to involve more than one member
of the same family
18. GENERAL SURVEY:
1. BUILD AND STATE OF NUTRITION:
• In thyrotoxicosis the patient is usually thin and
underweight. The patient sweats a lot with
wasting of muscles.
• In hypothyroidism the patient is obese and
overweight.
• In case of carcinoma of the thyroid, the
patient will have signs on anaemia and
cachexia.
19. 2. FACE:
• In thyrotoxicosis one can see
the facial expression of
excitement, tension,
nervousness or agitation with
or without variable degree of
exophthalmos.
• In hypothyroidism one can see
puffy face without any
expression
22. 4. SKIN:
•The skin is moist particularly the hands
of primary thyrotoxicosis.
•Hot and moist palm is a feature of
primary thyrotoxicosis.
•In myxedema the skin is dry, cool, pale
and inelastic.
23. 5. OTHER FINDINGS
• Not only the PR becomes rapid, but it becomes irregular in
thyrotoxicosis.
• Irregularity is more of a feature of secondary thyrotoxicosis.
• Particularly sleeping pulse rate is a very useful index to
determine the degree of thyrotoxicosis.
• In case of mild thyrotoxicosis it should be below 90
• In case of moderate or severe thyrotoxicosis it should be 90 – 110
and above 110 respectively.
• In hypothyroidism pulse becomes slow.
24. GENERAL EXAMINATION
• In general examination one should look for:
I. Primary toxic manifestations in case of goiters
affecting the young.
II. Secondary toxic manifestation in nodular goiter
III. Metastasis in case of malignant thyroid disease.
25. I. Primary toxic manifestations:
• One should look for 5 cardinal
signs:
a. Eye signs
b. Tachycardia or increase PR
without rise in temperature.
c. Tremor of the hands
d. Moist skin
e. Thyroid bruit 4 cardinal signs of primary toxic goiter shown
by numbers: (1) exophthalmos (2) thyroid
swelling with/without thrill (3) tachycardia (4)
tremor
26. a.Eye signs
•There are 4 important changes that may occur in
the eyes in thyrotoxicosis.
•Lid retraction
•Exophthalmos
•Ophthalmoplegia
•Chemosis
•Each one may be unilateral or bilateral
27. Lid retraction
• This is a condition where the
upper eye lid is higher than
normal and the lower lid is in
normal position.
• This sign is caused by over
activity of the involuntary
(smooth muscle) part of
palpebrae superioris muscle.
28. Exophthalmos
• When eye ball is pushed forward due to increase in fats or
edema or cellular infiltration in the retro orbital space, the
eyelids are retracted and sclera becomes visible below the
lower edge of the iris first, followed by above the upper edge
of the iris.
• The following are test or signs of exophthalmos.
• Von Graefe’s sign
• Joffroy’s sign
• Stellwag’s sign
• Moebius’ sign
• Dalrympte’s sign
29. Von Graefe’s sign
• The upper eye lid lags
the eyeball as the patient is
asked to look downwards.
Joffroy’s sign
• Absence of wrinkling on the
fore head when the patient
looks upwards with the face
inclined downwards
30. Stellwag’s sign
• This is staring look and infrequent
blinking of the eyes with widening of
palpebral fissure
• This is due to toxic contraction of
fibers of levator palpebrae superiosis.
Moebius’ sign
• This means inability or failure to
the eye balls
Dalrympte’s sign
• This means the upper sclera is visible
to retraction of upper eye lid
31. Ophthalmoplegia
• There may be weakness of the
ocular muscles due to oedema and
cellular infiltration of these
muscles.
• Most often the superior and lateral
rectus and inferior oblique muscles
are affected.
• Paralysis of these muscles prevents
the patient from looking upwards
and outwards.
32. Chemosis
•This is oedema of the conjuctiva.
•The conjuctiva becomes
oedematous, thickened and
crinkled.
•Chemosis is caused by obstruction
of venous and lymphatic drainage
of the conjuctiva by the increased
retro-orbital pressure
33. b. tachycardia
• Tachycardia or increase PR without rise in
temperature is constantly present in primary toxic
goiter.
• Sleeping pulse rate is more confirmatory in
thyrotoxicosis.
• Regularity of the pulse may be disrupted and a rapid
irregular pulse should arise suspicion of auricular
fibrillation.
34. c. Tremor
• Tremor of the hands (a fine tremor) is almost always present
in a primary thyrotoxic case.
• Ask the patient to straight out the arms in front and spread
the fingers.
• Fine tremors will be exhibited at the fingers
• The patient is also asked to put out the tongue straight and to
keep it in this position for at least ½ a minute.
• Fibrillary twitching will be observed
• In severe cases the tongue and fingers may tremble
35.
36. d. Moist skin
• Moist skin particularly of the hand and feet are quite
common in primary thyrotoxic cases.
• It should be a routine practice to feel the hands just
after feeling the pulse at the wrist.
• The palms are hot and moist and the patients can not
tolerate hot weather, on the contrary tolerance to
cold is increased.
37. e. Thyroid bruit
•Thyroid bruit is quite characteristic in Graves
disease (primary thyrotoxic goiter).
•This is due to increased vascularity of the gland.
•But this sign is relatively late sign and mostly
heard over the lateral lobes near their superior
poles.
38. II. Secondary thyrotoxicosis
• May complicate multinodular goiter or adenoma of the thyroid
• The cardiovascular system is mainly affected.
• Auricular fibrillation is quite common
• The heart may be enlarged
• Signs of cardiac failure such as oedema of the ankles, orthopnea,
dyspnoea while walking up the stairs may be observed.
• Exophthalmos and tremor are usually absent
• Patients in this group are generally elderly
39. iii. Search for metastasis
• When the thyroid swelling appears to be stony hard, irregular and
fixed, a careful search should be made to know about the spread of
the disease.
• Besides examining the cervical lymph nodes, one should also look for
distant metastases which is quite common in thyroid carcinoma
particularly the follicular type.
• The skull, spine, ends of long bone and pelvis should be examined for
metastatis
• Lastly metastatis in the lungs, which is not uncommon should also be
excluded.
41. •Examination of the thyroid swelling
should begin with the general
principles of examination of any
swelling.
•Here only those peculiar to the
thyroid gland will be discussed.
42. Inspection:
• Normal thyroid gland is not obvious on
inspection.
• It can be seen only when the gland is swollen.
• In case of obese and short necked individuals
inspection of the thyroid gland becomes difficult.
• To render inspection easier one can follow
Pizzilo’s method in which the hands are placed
behind the head and the patient is asked to push
his/ her head backwards against her clasped
hands on the occipitus.
43. • Ask the patient to swallow and
watch for the most important
physical sign – a thyroid gland
moves up during deglutition.
• This is due to the fact that thyroid
gland is fixed to the larynx.
• Such movement of the thyroid
becomes greatly limited when it is
fixed by an inflammation or
malignant infiltration.
44. • In retrosternal goiter, pressure on the great veins at
the thoracic inlet gives rise to dilatation of the
subcutaneous veins over the upper anterior part of
the thorax.
• When these are present ask the patient to swallow
and determine, on inspection, the lower border of
the swelling as it moves up on deglutition.
• This is not possible in case of retrosternal goiter.
• The patient should be asked to raise both arms over
his head until they touch the ears.
• This position is maintained for a while.
• Congestion of face and distress becomes evident in
the case of retrosternal goiter due to obstruction of
the great veins at the thoracic inlet.
45. Palpation:
• The thyroid gland should always be palpated
with the patients neck slightly flexed.
• The gland may be palpated from behind and
from the front.
• The patient should be seated on a stool and
the clinician stands behind the patient.
• The patient is asked to flex the neck slightly.
• The thumbs of both hands are placed behind
the neck and the other four fingers on each
hand are placed on each lobe and the
isthmus.
46. • Palpation of each lobe is best carried out by Lahey’s method.
• In this case the examiner stands in front of the patient .
• To palpate the left lobe properly the thyroid gland is pushed to the left from the
right side by the left hand of the examiner.
• This makes the left lobe more prominent so that the examiner can palpate it
thoroughly with his right hand.
• During palpation the patient should be asked to swallow in
order to settle the diagnosis of thyroid swelling.
• Slight enlargement of the thyroid gland or presence of nodules in its
substance can be appreciated by simply placing the thumb on the
thyroid gland while he patient swallows (Crille’s method)
47. • During palpation the following points should be noted:
i. Whether the whole thyroid gland is enlarged?
• if so note its surface - whether it is smooth (primary thyrotoxicosis
or colloid goiter) or bosselated (multinodular goiter) and its
consistency whether uniform or variable.
• It may be firm in primary thyrotoxicosis , Hashimoto’s disease etc.
• It is slightly softer in colloid goiter
• Hard in Riedel’s thyroiditis or carcinoma in which the consistencies
may be variable in places.
48. ii. When a swelling is localized
• Note its position, size, shape and its consistency
iii. The mobility should be noted in both horizontal
vertical planes.
• Fixation means malignant tumor or chronic thyroiditis
iv. To get below the thyroid gland is an important
test to discard the possibility of retrosternal
• Clinicians index finger is placed on the lower border
gland.
• The patient is asked to swallow
• The thyroid gland will move up and the lower border
carefully for any extension downwards.
49. v. Pressure effect from the thyroid swelling should be
carefully looked for.
• Pressure may be on the trachea or larynx, esophagus and
recurrent laryngeal nerve.
• If pressure on trachea is suspected slight push on the
lateral lobe will produce stridor (Kocher’s test).
• Gentle compression on the lateral lobe may produce stridor
• This is due to narrowed trachea
• This test is particularly positive in multinodular goiters and
carcinoma infiltrating into trachea narrowing it.
50. • The position of the larynx and trachea should also be noted.
• This may be accessed by placing stethoscope on the suspected zone
• Passage of air will indicate the position of the trachea.
• Simple palpation by an experienced hand will also indicate the position of the
trachea.
• A malignant thyroid may engulf the carotid sheath completely and the
pulsations of the artery can not be felt.
• Sympathetic trunk may also be affected by a thyroid swelling.
• This will lead to Horner’s syndrome
• Slight sinking of the eye balls into the orbit (enophthalmos)
• Slight drooping of the upper lid (pseudoptosis)
• Contraction of the pupil (miosis)
• Absence of sweating on the affected side of the face (anhidrosis)
51.
52. • Obstruction of the major veins in the thorax causes
engorgement of the neck veins.
• This sign becomes obvious when the patients are asked to raise
the hands above the head and the arms touch the ears.
• This is known as Pemberton’s sign
53. vi. Whether there is any toxic manifestation or
not.
• Primary toxic thyroid is generally not enlarged
• An enlarged thyroid or nodular thyroid with toxic
generally a case of secondary thyrotoxicosis.
vii.Palpation of cervical lymph nodes.
• This is extremely important particularly in
• Occasionally only cervical lymph nodes may be
thyroid gland remains impalpable.
• Papillary carcinoma of the thyroid is notorious for
metastasis while the primary tumor remains quite
54.
55. Percussion:
•This is employed over the manubrium
sterni to exclude the presence of a
retrosternal goiter.
•This is more of a theoretical importance
rather than practical
56. Auscultation:
• In primary toxic
goiter a systolic
bruit may be
heard over the
goiter due to
increased
vascularity.
