Introduction
Wash hands
Introduce yourself
Confirm patient details – name / DOB
Explain the examination
Gain consent
Ask the patient to sit down
Adequate exposure - access to the patient's neck
Check understanding with the patient, ask if they have any questions
General Inspection
Introduction
Wash hands, Introduce self, ask Patients name & DOB & what they like to be called, Explain examination and get consent
Expose patient’s neck
Gather your equipment --> Stethoscope, Piece of paper, glass of water, tendon hammer
General Inspection
Patient: stable, posture, anxious/ nervous, hot/ cold, facial complexion (myxoedema, flushed), obvious muscle wasting, BMI, obvious swellings, dry hair/ waxy skin, hair loss
Around bed
Hands:
Fine tremor: patient holds arms and hands stretched out, fingers straight and separated. This can be easily seen if you place a sheet of paper on top of the patient's hands. (hyperthyroidism)
Thyroid acropachy - phalangeal bone overgrowth (Graves)
Dry palms (hypothyroidism)
Sweaty/moist/clammy palms (hyperthyroidism)
Palmar erythema (thyrotoxicosis)
Pulse (tachycardia and AF in hyperthyroidism)
Pulse (bradycardia in hypothyroidism
Face
Sweating (hyperthyroidism), Dry skin (hypothyroidism)
Hair loss - especially outer 1/3 of eyebrows (hypothyroidism)
Myxoedema - giving the skin a waxy consistency (hypothyroidism)
Eyes: lid retraction (upper eye lid), exophthalmos (sclera above and below iris), proptosis (forward protrusion of eye; look from above and side)
Bilateral exophthalmos is associated with Graves’ disease.
Exophthalmos = anterior displacement of the eye out of the orbit
Extra-ocular muscles: H-test and ask about diplopia
Eye movements can be restricted in Graves’ disease as a result of abnormal connective tissue deposition in the orbit and extra-ocular muscles.
Lid lag: follow fingers downwards
If lid lag is present, the upper eyelids can be seen 'lagging' behind the eyes’ downward movement. Lid lag occurs due to exophthalmos which is associated with Graves’ disease.
Neck
Inspection (from front): swellings, scars, swallow, stick out tongue (thyroglossal cyst moves on tongue protrusion) ,
Note: The normal thyroid gland should not be visible on inspection
Hands above head (Pemberton’s sign = retrosternal goitre compresses SVC and results in venous congestion)
Thyroid gland
Place the three middle 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
The first two rings of the trachea are located below the cricoid cartilage and the thyroid isthmus overlies this area
Palpate the thyroid isthmus using the pads of your fingers
Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus
Note: Size, symmetry, consistency, masses, movement
Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass)
Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it will rise during tongue protrusion)
Percussion
Percuss downwards from sternal notch
Retrosternal dullness may indicate a large thyroid mass.
Auscultation
Each lobe for a bruit: A bruit would suggest increased vascularity, which occurs in Graves’ disease.
A bruit would suggest increased vascularity, which occurs in Graves’ disease.
Lymph nodes
Palpate for local lymphadenopathy:
Supraclavicular nodes
Anterior cervical chain
Posterior cervical chain
Submental nodes
Finally
Reflexes (increased in hyperthyroidism, decreased in hypothyroidism)
Inspect for pretibial myopathy: Graves
To complete
Thank patient
Summarise and suggest further investigations you would do after a full history (e.g. TFT's, thyroid USS, ECG if AF noted during examination)
Questions:
Give 2 examination findings that are specific to Grave's disease
Give 2 differential diagnoses of an enlarged thyroid gland
Raised TSH, low T4 - what is this?
What is exophthalmos? In what condition might it be present?
Name 2 management options for a patient with hyperthyroidism?
What thyroid supplementing medication is often given after a total thyroidectomy?
What medication can be used to control tachycardia/palpitations?
What symptoms might a patient with hypothyroidism be complaining of?
Name an 'emergency state' that a patient with thyroid disease may present as
On palpation, how would you clinically describe a thyroid gland?
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