reference purpose only

1. Thyroid Examination
Dr Shamshad
Majmaah Medical College
KSA

2. Objectives
1. Differentiate the common symptoms of hypothyroidism and
hyperthyroidism.
2. Demonstrate perfectly thyroid examination techniques
including inspection, palpation and auscultation.
3. Perform the correct technique of thyroid examination.
4. Recognize common abnormalities of thyroid gland like goiter
and nodules.
5. Apply clinical maneuvers to assess the functional status of the
thyroid gland.
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3. Signs and symptoms
Hypothyroidism
1. Fatigue
2. Weight gain
3. Cold intolerance
4. Depression or memory
impairment Menstrual
irregularities (menorrhagia),
infertility
5. Weakness, muscle cramps, joint
pains
6. Hoarseness
7. Hypersomnolence
Hyperthyroidism
1. Fatigue
2. Weight loss without change in
appetite
3. Heat intolerance
4. Depression or nervousness,
irritability,
5. anxiety or agitation
6. Menstrual irregularities
(Oligomenorrhea)
7. Weakness, tremor Palpitations
8. Exertional dyspnea
9. Constipation Hyperdefecation
10. Anterior neck pain
11. Insomnia
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4. Risk Factors
Hypothyroidism
 Family or personal hx of
thyroid disease
 Goiter or hx of goiter
 Prior or current thyroid use
Hyperthyroidism
 Family or personal hx of
thyroid disease
 Goiter or hx of goiter
 Prior or current thyroid use
 Hx of other autoimmune
disease
 Recent iodine exposure
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5. Hypothyroidism
1. The elderly may present
atypically with isolated
symptoms of fatigue,
constipation, weight gain
or depression.
Hyperthyroidism
1. The elderly may present
atypically
2. "apathetic hyperthyroidism"
symptoms resembling
hypothyroidism in younger
patients OR
3. Isolated unexplained weight
loss
4. H/o congestive heart failure
(CHF)
Atypical Presentation in the Elderly
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6. Equipment required
1. Simulated patient OR Thyroid manikin
2. Hand sanitizer
3. watch
4. Disposable gloves
5. Weighing machine
6. Water bottle
7. Plain paper
8. Measuring tape.

7. General Principles & Etiquettes
 Meet, greet, introduce
 Verbal Consent
 Explain to patient
 Hand Washing
 Be polite: say “please” & “thank you”
 Patient Comfort
 Thank the patient and cover at the end

8. General Examination
General look:
8
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9. Look for ..VDAAASH
 Voice sound normal? husky, monotonous
 Demeanour, mental state
 Abnormally hyper- or hypoactive…
 Appearance e. g central obesity
 Appear sweaty?
 Skin: Vitiligo, non pitting edema
 Hair :Thin, frontal baldness, Hirsuitism.
…General Examination
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10. ..Hand Examination :SPPTNP
 Large sweaty fleshy hands
 Palmar erythema (hyperthyroidism)
 Pigmentation of hand crease
 Tremor : fine or coarse
 Nails : Acropachy (similar to clubbing), or Onycholysis (nail
comes away from the nail bed).
 Pulse :Tachy, bradycardia or AF.
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11. ..Face and Chest Examination
Face :
Features of Cushing syndrome & acromegaly
Neck:
 Neck swelling (goitre)
 Cervical lymph nodes
 Obvious abnormalities, scars or swellings..
Breasts:
a. Gynaecomastia
b. Galactorrhoea
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12. .. Examination of the Eyes
Exophthalmos
Ophthalmoplegia
Visual field defect
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13.  Muscles power : Proximal myopathy
 Pretibial myxedema
 Tendon reflexes :Hypo or
hyperreflexia
..Arms and legs
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Genitalia
a. Virilization
b. testicular volume
c. pubertal development

14. Examination of the Thyroid Gland
1. Inspection
2. Palpation
3. Percussion
4. Auscultation for bruit
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15. Comment on the thyroid gland:
SPACES PIT
 Size: Enlarged
 Position: midline /lateral
 Attachment: to underlining structures : Malignancy
 Consistency: Firm: Hashimotos disease, primary
thyrotoxicosis; Soft: colloid goitre; Hard: Riedel’s thyroiditis;
Variable: carcinomas
 Edge :
 Surface and shape: Smooth :primary thyrotoxsis;colloied
goitre, multinodular goitre
 Pulsations: carotid pulsation;thrill
 Inflammation
 Transillumination
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16. 1: Anterior approach
Inspect the neck standing in
front of patient.
The patient should be seated
standing in a comfortable
position with the neck in
neutral of slightly extended
position.
Inspection
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17. Ask the patient to protrude the tongue
Observe the movement of mass
No movement:
Thyroid gland mass or lymph node
Upward movement:
Thyroglossal cyst
I: Midline neck swelling
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18. II: Skin changes: Erythema, ulceration,…
III: Scars: Previous surgeries , post infection…
IV Pulsation: Carotid pulsation
V Mass:
Ask the patient to swallow sip of water thyroid mass moves upwards
2: Lateral approach:
Observe the neck from the side
To estimate smooth, straight
contour from the cricoid cartilage
to the suprasternal notch.
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19. Palpation of thyroid gland
1. Posterior approach
2. Anterior approach
Ask if the patient feels tenderness /pain
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20. Palpation
Place 3 fingers of each hand along the midline of the neck below
the chin
Locate the upper edge of the thyroid cartilage (Adam’s apple)
Move inferiorly until you reach the cricoid cartilage palpate thyroid
isthmus with pads (not with tip ) of fingers
Palpate the lateral lobes of thyroid & inferior borders of thyroid
Ask the patient to
1: swallow sip of water feel for symmetry (asymmetry : unilateral
mass)
2: Protrude the tongue once more (confirm : Thyroglossal cyst)
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21. 1. Posterior approach
Stand behind the patient and ask
to slightly flex the neck to relax
the sternocleidomastoid (neck)
muscle
Place your hands either side of
neck
Ask if the patient feels
tenderness
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22. Anterior approach
Examine from the front
The normal lobe of thyroid is
pushed to side of nodule so that
solitary nodule can be made
prominent and palpated well
Stand in front.
Elevate and Rotate the chin
slightly towards the side of the
lobe to be palpated to relax the
sternomastoid.
Place the thumb against the
lower lateral portion of the
thyroid cartilage.
Lahey’s method
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23. This method involves placing the thumb on the
thyroid gland and asking the patient to swallow
.Small thyroid nodules within the thyroid gland can
be palpated by this method
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Crile's method

24. Comment on the thyroid gland
 Size
 Position
 Attachment
 Consistency
 Edge
 Surface and shape
 Pulsations:
 Inflammation
 Transillumination
SPACES PIT
Multinodular goiter
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26. Percussion
Over manubrium sterni : retrosternal extension
Neck circumference :
To monitor the growth rate of swelling
Auscultation
Systolic bruit: Primary toxic goitre
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27. • References:
• 1. http://www.osceskills.com/e-learning/subjects/rectal-examination/#sthash.yG3uvPXH.dpuf
• 2. Oxford Handbook of Clinical Examination and Practical Skills, by Vishal, 1st edition (2007).
• 3. http://www.uptodate.com.
• 4. Hutchison’s Clinical Methods: An Integrated Approach to Clinical Practice, 22nd edition
• (2007), by Michael Glynn and William M Drake.
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