endocrine - thyroid examination

thyroid is a component of semester 4 - endocrine system.
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flow of events

1.       greet, Intro, Explanation, Permission

2.       Wash hands

3.       general inspection

4.       inspection and palpation of the hands

5.       inspection and palpation of the arms

6.       inspection of the eyes and face

7.       inspection of the neck

8.       palpation of the neck

9.       percussion of chest

10.   auscultation for bruits

11.   test for proximal myopathy

12.   assess any lymphadenopathy in the neck

13. thank, wash hands, leave.

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general inspection

the examination of thyroid diseases starts from general inspection, if not history taking.

Look at the patient. Does s/he look excited, impatient or nervous? (hyper thyrodism) or depressed, apathetic, or unresponsive (hypo-thyrodism)

Look at the patient’s gaze. A “thyroid-stare” may be observed which is very characteristic of grave’s disease.

Look at the patient’s face. An obviously puffy eyes and thickened, pale skin may be a tell-tale signs of hypothyrodism. s/he may also look apathetic with slow responce.

Look at his/her clothes. If s/he is wearing loose clothes, it may be due to the fact that s/he has been losing weight. (hyperthyroidism)

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Inspection and palpation of hands (and legs)

The things you should look out in hands;

·         Hypothyroid signs;

·         dry coarse skin

·         cool peripheries and peripheral cyanosis.

·         puffy hands (myxedema) – myxedema is an accumulation of hydrophilic mucopolysaccharides in the ground substance in the tissues including the skin. The skin is doughy to touch and thick.

·         bradycardia

·         peripheral edema

·         carpel tunnel syndrome (try compressing the patient’s hands)

·         there may be a yellow discolouration of palms due to carotene accumulation – due to slower hepatic metabolism of carotene.

·         Hyperthyroid signs

·         tachycardia

·         tremor

·         warm, moist skin

·         acropachy (only in grave’s. it is clubbing but it is not called clubbing)

·         onicholysis (separation of nailbed) /plummer’s nails

·         muscle weakness (thinning of muscles in tinna and hypotinna)

·         pretibial myxedema (non-pitting swelling of lateral aspect of shins of the legs)

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inspection and palpation of the arms

·         hold the arm and feel the temperature if its cold (hypo) or hot (hyper).

·         you could also pinch the skin if its thick of myxedema of hypothyroidism

·         test for fine tremor (hyperthyroidism, due to sympathetic overactivity)
remember to use a paper.

·         Note the pulse. 

·         presence of sinus tachycardia or irregularly irregular (atrial fib) due to a shortened refractory period due to sympathetic drive and hormone-induced changes in hyper thyrodism

·         Small volume and slow pulse in hypothyroidism.

·         Test for biceps reflex

·         Hyperreflexia in hyperthyroidism

·         Hung-up reflex in hypothyrodism

·         Test for phalen’s sign – carpel tunnel syndrome due to myxedema
(phalen’s manoeuvre involves pressing the dorsum of both hands together for 30 seconds.) positive sign is the characteristic tingling/pain. (OPTIONAL in IMU)

·          

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inspection of the eyes and face

·         Graves disease has a very characteristic “thyroid stare” where the patients will have retracted lids and proptosis that s/he will look like s/he is staring intensely. (it is more formally called Dalrymple's sign)

·         The whites of the eyes noted below and above the pupil are called “limbus”.

o   If you notice an upper limbus, this may indicate lid-retraction.

o   If you notice a lower limbus, it may indicate proptosis - however you may see lower limbus in certain ethnic groups e.g. Indians. This is normal.

·         Observe the eye from front, sides and top to assess the level of proptosis.

after which you can illicit Graefe's sign (lid-lag) by letting the patient follow your finger from up to down. The eye will follow the finger, but the lid will lag behind the movement of the eye.

You may impress the examiner greatly by mentioning if there are any surgical scars for previous “Tarsorrhaphy” you will see this in the form of stitch-marks around the eye.

·         Assess if the patient has diplopia by asking the patient how many finger he sees (you will only show him one finger) when the patient looks laterally or up.

       in diplopia, the patient will have double vision in lateral or upper field.

·         When the proptosis is so advanced, patient may have other visual defects such as corneal infection or even blindness.

·         If ptosis is observed, rule out myasthenia gravis, which can be associated with autoimmune disorders

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Inspection of the neck

The normal thyroid may be just visible in a thin young individual below the cricoid cardtilage.

Look at the patient’s neck from the front, sides and back and note any;

·         swelling

·         mass – look for goitre / thyroglossal cyst.

·         discoloration – there may be red discolouration in case of suppurative thyroditis.

·         engorged vessels – dilated veins may be present in retrosternal extension of the goitre, at the upper part of chest wall. Also the external jugular will be prominent. - due to the obstruction to the thoracic outlet.

·         surgical scars – thyrodictomy scar forms a ring around the base of the neck like a high necklace.

If there is a mass, ask the patient to swallow a sip of water. Watch the mass as the patient to swallow. Make sure you get ready before you instruct patient to drink.

Only a goitre or a thyroglossal will rise with swallowing due to attachment to the larynx. Also note if the inferior border of mass is seen as the mass rises.

You could also ask the patient to stick out his/her tongue. A thyroglossal cyst will move with sticking out of tongue because the cyst extends from foramen caecum of tongue.

Goitre will not.

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palpation of the neck

now you can finally touch your patient’s neck.

No. Actually, not yet. You still have to rub your hands, ask if there is any pain, and ask if your hands are warm enough.

Ask the patient to relax, look forward and down on the floor 5 feet away (doesn’t really matter how you say it, so as long as the patient relaxes neck)

BUT WAIT. what if the patient has a carotid artery stenosis or a friable thrombus? - it is good practice to AUSCULTATE the neck before palpation. (perhaps not standard precaution, but personally this makes a lot of sense. It would feel horrible to find a carotid bruit after throughly palpating the neck or worse... throwing a thrombus up the brain then finding out that maybe auscultation was best done before palpation) 

1.       First, you may place your palm on the frontal neck of patient to assess the temperature. In thyroditis, the neck may be warm.

2.       Now, from behind, you may feel the thyroid cartilage. The thyroid gland lies just below the cricoid cartilage. Look at your patient for any grimaces (tenderness)

3.       You may palpate the isthmus, then the left lobe, then the other.

4.       Actually you can palpate any way you want,  so as long as you do it systematically. My method is where you Hold one end of the thyroid gland when palpating the other so that the gland doesn’t move around and you don’t jab.

5.       Next, you may ask the patient to hold the cup of water. And wait for your command to drink.

6.       Place your fingers above the thyroid gland, and ask the patient to drink the water.
shall there be a mass, you will try to comfirm it moving with the thyroid, and try to get to the bottom edge of the thyroid, as the thyroid moves up (if there is a mass)

7.       You may also ask the patient to stick their tongue out, just to exclude thyroglossal cyst.

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percussion of chest

you could percuss the sternum of the patient to assess retrosternal spread of goitre.

Goitre can also be present in the supraclavicular, clavicular, infraclavicular area. Percuss these just in case.

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auscultation for bruits

in hyperthyroidism, there may be an increase in vascularity.

Thyroid bruits can be differentiated from carotid by noting if there is any correlation with the pulse. Carotid bruits will be louder on systole. Thyroid bruit is constant.

To assess bruits, ask patient to breath in-out-hold-listen

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test for proximal myopathy

test proximal myopathy by either testing the shoulder muscle (just like motor exam, you ask patient to resist you) or asking the patient to sit, stand, sit, stand, … on a chair.

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Other tests

You may want to observe pretibial edema in hyperthyroidism patient.


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The awesome table of thyroid pathology

Name	Pattern of thyroid swelling	Other clinical manifestations	Presence of pain	Epidemiology
Hyperthyroid
Diffuse toxic hyperplasia (Grave’s)	Diffuse - more chronic case may present in nodular pattern. May have thyroid bruit.	Very specific signs include; thyroid opthalmopathy dermopathy (pretibial myxedema) onycholysis.	Nontender	60-90% of all thyrotoxicosis in world.
Toxic Multinodular (plummer’s syndrome)	Multinodular. There may be substernal goitre. Some are progressions from non-toxic multinodular goiter.	More subtle hyperthyroidism. NO orbitopathy NO pretibial myxedema, NO acropachy	Nontender	Where there is endemic iodine deficiency, accounts 58% of hyperthyrodism
Adenomas of thyroid (SOME are “toxic adenoma”)	Usually solitary, painless nodule.	Difficulty in swallowing.	nontender	Rare.
Hypothyroid
Hashimoto’s Thyroditis (chronic lymphocytic)	Firm, rubbery. Symmetric and diffuse enlargement, but some cases show localization to raise suspicion of neoplasm	Hypothyroidism develop slowly, sometimes causes hyperthyroidism (hashitoxicosis) Increased risk for B-cell lymphomas	nontender	Most prevalent bet. 45-65, female dominance (10-20:1) Can occur in children 0.3-1.5/1000 incidence
De Quarvin (subacute granulomatous)	Usually symmetrical but sometimes starts at one lobe. Firm There may be erythyma and warmness in severe cases	Fever, malaise, anorexia Hyperthyroidism in Half the cases, hypo in late stages NO exophtalmous	Very Painful	Less than 5% of thyroid pathology. Tends to follow viral epidemics.
Postpartum thyroditis (subacute lymphocytic)	Transient, mostly no swelling, sometimes diffuse slight swelling.	All the post-partum syndromes	Nontender	About 10% of women after delivary
MAYBE euthyroid
Diffuse / multinodular goiter	Diffue then multinodular. May than progress to a toxic multinodular thyrodism.	Mass effects of thyroid swelling- airway obstruction, dysphagia, vessel obstruction etc.	Nontender.	Most common thyroid disorder- mostly due to iodine deficiency.
Acute suppurative thyroditis	May be unilateral, tender, red and warm nodule. May be ascess and lymphadenopathy.	Fever and systemic infective signs.	Neck tenderness, swollen thyroid is tender	Rare in western nations.
Papillary carcinoma	Palpable, firm, nontender. Fixed.	Paraneoplastic syndromes	Nontender	74-80% of thyroid cancers (thyroid cancer 1.5% of all cancers in adults, 3% in children)
Follicular carcinoma	Hard, solitary nodule, fast-growing, fixed	Paraneoplastic syndromes	Nontender	10-15% of thyroid cancers

"woody" thryroid - riedel

·         Non-thyroid causes of hypothyroidism -

o   Central hypothyroidism (Hypothalamic - pituitary axis damaged)

§  Pituitary adenoma

§  Brain irradiation

§  Drugs

·         Dopamine, lithium

§  Sheehan $

§  Genetic disorders

o   Iatrogenic

§  Surgical removal of thyroid gland

§  Irradiation of thyroid

o   Metabolic

§  Inborn erroes of thyroid hormone synthesis (rare)

o   Drugs

§  Amiodarone

§  Interferon alpha

§  Thalidomide

§  lithium

optional knowledge - NOSPECS assessment of severity of Grave's Opthalmopathy

0 - No signs or symptoms

1 - Only signs, no symptoms (e.g. lid-lag, stare, lid retraction)

2 - Soft tissue involvement

3 - Proptosis

4 - Extraocular muscle involvment

5 - Corneal Involvement

6 - Sight Loss (Optic Nerve)