By Dr. Usama Ragab, Zagagzig Faculty of Medicine Applied Anatomy Clinical examination Techniques Pitfalls Conclusions and recommendations

1. Thyroid Examination
Usama Ragab Youssif
Zagazig Faculty of Medicine

2. Applied Anatomy
Parts of thyroid:
-2 lobes.
-Isthmus.
- ± Pyramidal lobe (in the upper border of the isthmus).

3. Applied Anatomy (cont.)
Each lobe measures:
- 4 x 2.5 x 2 cm
Position:
-In the lower part of the neck opposite C5,6,7 vertebrae.
-Muscular triangle.
-Apex paralel to oblique line of thyroid cartilage.
-Base at level of 6th tracheal ring.
-Isthmus lies opposite the 2nd, 3rd and 4th tracheal ring.

4. Applied Anatomy (cont.)
Capsule:
-True: from the CT of the gland.
-False: from the pretracheal fascia.

5. Applied Anatomy (cont.)
Lymphatic drainage:
-Peripheral part: Upper and lower deep cervical LN.
-Medial parts of Lobes and isthmus:
1- Prelaryngeal and pretracheal LN.
2- Superior mediastinal LN.

6. History
Personal: NAS OMRHH
-Age group.
-Sex.
-Occupation and Travel History.
-Marital status, menstrual, obstetric and sexual history.
-Residence: endemic areas away from sea???
Complaint: + duration
-Neck swelling.
-Symptoms of hyperfunction.
-Symptoms of hypofunction.
Pain Swelling Disturbance of function

7. History (cont.)
A- Swelling +/- pain.
B- Local Effect.

8. History (cont.)
C- General effect
1- Symptoms of thyrotoxicosis:
- Unintentional weight loss.
- Hot intolerance.
- Excess sweating.
- CVS: palpitation.
- Resp: S.O.B.
- GIT: hyperdefecation.
- CNS: tremors, nervousness, insomnia.
- Bony ache.
- Genital: menstrual irregularitis, ED in males.

9. History (cont.)
C- General effect
2- Symptoms of hypothyroidism:
- Weight gain: fail to loose weight.
- Bloated.
- Tiredness, loss of interest, poor memory.
- CVS: palpitation.
- Resp: S.O.B. (pleural effusion?)
- GIT: constipation, diarrhea?!.
- Bony ache.
- Genital: menstrual irregularitis, ED in males.

10. History (cont.)
C- General effect
3- Symptoms of malignancy:
- Night fever, loss of weight and appetite.
- Local mets symptoms.
- Remote mets symptoms.

11. History (cont.)
Past history:
Drugs: cause thyroid disturbance or interfere with other.
Operations: thyroid, neck.
Irradiation.
Other related illness: vitiligo, DM, pernicious anemia.
Family history:
Similarities.
Autoimmune disorders.

12. Examination (General)
Vital signs:
Pulse (+ sleep pulse) (New onset AF).
Temperature.
Blood pressure.
Respiratory rate.
General overview:
Appearance.
Built
Color
Decubitus
Exposure (Back, breast, genitalia)
Facial expression
Gait

13. Examination (General)

14. Examination (General)
Head to toes examination:
HEENT
Neck and thyroid
Upper limb
Lower limbs

15. Examination (General)

16. Examination (General)

17. Examination (General)

18. Examination (General)

19. Examination (General)
Other systems screening:
CVS: sinus tachy, Lerman scratch, flow murmur.
Chest: metastasis to chest wall, mediastinal syndrome
Neurologic: neuropathy, myopathy
Abdomen: organomegaly.
Back

20. Examination (General)
Eye examination:
Naffziger test.
Frazer test.
Ruler test.
Hertel’s exophthalmometer.

21. Examination (General)
Special eye signs:
Stellwag sign: serpentine look
Dalrymple sign.
Mobius sign.
Joffroy sign.
von Graefe’s sign.
Griffith sign.
Rosenbach sign.
Topolansky sign.
Jellinek sign.
Tellas sign.

22. Examination (General)
Special eye signs

25. General rules
-Don’t strangle your patient.
-Don’t press so much (if you press, you miss).
-Swallow is the magic word.

26. Examination (Local)
A- Inspection: from front and sides.
-Swallow.
-Assess scar asymmetry or masses.
B- Palpation.
-Assess lobes and isthmus (search pyramidal lobe)
-Don’t forget LN++ - Perry’s sign of absent carotid.
C- Percussion.
-For retrosternal goitre or superior mediastinal LN.
D- Auscultation.
-For bruit, stridor?
E- Special test.
-Pemperton test. - Kocher test of tracheomalacia
-Deglutition test. - Tongue protrusion test.

29. General rules (revision)
-Don’t strangle your patient.
-Don’t press so much (if you press, you miss).
-Swallow is the magic word.