THYROID EXAM

Required Tools

Knock, enter the room, wash/sanitize hands and introduce yourself
Greet the patient, ask the patient’s name, explain the exam and ask for consent
Always take vitals
- Note: Bradycardia can be seen in hypothyroidism and tachycardia can be seen in hyperthyroidism. SBP can be elevated in hyperthyroidism, whereas in hypothyroidism the DBP may be increased which raises the pulse pressure (pulse pressure is the difference between SBP and DBP). Temperature may be elevated in hyperthyroidism and decreased in hypothyroidism due to changes in the basal metabolic rate.
Advise and request patient to drape according to the exam being performed (mention what type of exposure is necessary)
- Expose the neck from the chin down to the level of the manubrium & clavicles

Patient can sit on the examination table for the inspection exam

Head	Inspect for upper eyelid retraction (sclera visible above the cornea) and lid lag (movement of eyelid lags behind the eye). Signs specific for Graves ophthalmopathy are: exophthalmos (bulging of the eye) and chemosis (erythema and swelling of the conjunctiva). Signs of hypothyroidism include periorbital edema, macroglossia, and glossitis, as well as thinning of the hair and loss of the lateral third of the eyebrow.
Neck	Inspect neck from the side and front. Look for scars (thyroidectomy), masses, (maybe lymph nodes or goiter), or swelling. May be able to see more clearly if patient extends their neck. Have patient take a sip of water and swallow, thyroid should move up and down as patient swallows.
Hands	In hypothyroidism: skin that is dry, cold, pale, coarse. May see onycholysis in both hyper and hypo, but more common in hyper. In hyperthyroidism: fine tremor by placing paper on outstretched hands with palms facing down, sweating palms, palmar erythema.
Legs	Inspect for pretibial myxedema, may see skin changes like peau d’orange (waxy discolored induration of skin) which is typical of Graves.

Transition statement and consent to begin palpating
Setup: have glass of water next to the patient and inform them that you may ask them to sip at certain points
Palpate the thyroid gland
- Can palpate from the posterior or anterior approach, both are correct
- Landmark the isthmus by locating the thyroid cartilage (C4-5), move finger inferiorly along midline until cricoid cartilage (C6). Isthmus is just below the cricoid cartilage.
- Palpate gland by moving sternocleidomastoid out of the way and palpating around the area with other hand while having the patient turn their head to the left and then to the right allowing you to feel the edges of the gland. When palpating, use the pads (not tips) of 2 digits on either lobe of the thyroid gland
  - Assess:
    - Size
    - Nodularity- a palpable nodule is usually at least 1.5cm in size
    - Consistency
    - shape/symmetry
    - Tenderness
  - Typical presentations:
    - Grave’s Disease (Hyperthyroid): Soft, diffusely enlarged, and soft with no nodules
    - Hashimoto’s Thyroiditis (Hypothyroid): Firm, diffusely enlarged, and slightly tender with no nodules
    - Malignancy: Firm, singular nodes
    - Iodine Deficiency: Multinodular goiter
- Tongue protrusion- ask the patient to protrude their tongue. This is done to detect whether a palpable mass is a thyroglossal cyst or a thyroid gland mass. A thyroglossal cyst will move upward with tongue protrusion while a thyroid gland or lymph node will not

Use diaphragm of stethoscope to listen for thyroid bruits
- Ask patient to hold their breath
- Auscultate both lobes of thyroid gland
- May be heard in Graves due to increased vascularity of the gland

Lid Lag Test
- Stand >1m away from patient and have patient follow your finger without moving their head
- Positive test: lids will move more slowly than the eyes
  - Normally, they should be moving simultaneously
Pemberton’s Sign
- Have patient raise their arms above head for 1 minute
- Look for signs of facial congestion and cyanosis, respiratory distress
- This indicates venous obstruction which can be due to many things, one of which is a large goiter.
Proximal Muscle Weakness
- Have patient stand up from a chair without using their arms
  - Alternative: lift up their arms against resistance
  - Proximal muscle weakness can be seen in hypothyroidism
Deep Tendon Reflexes
- Assess bilateral symmetry and briskness of response
  - Patellar reflex
  - Brachialis reflex
  - Triceps reflex
  - Achilles reflex
- Grading: 0 is absent (abnormal), 1+ is slight (normal or abnormal), 2+ is brisk (normal set point), 3+ is very brisk (normal or abnormal), 4+ is clonus (repeating reflex, abnormal)
- Typical Presentations:
  - Hyperreflexia (3+ or 4+) characteristic of Hyperthyroidism
  - Hyporeflexia (0 or 1+), specifically a delayed relaxation phase, is characteristic of Hypothyroidism most easily seen at ankle reflex