1. Thyroid exam Wishvan Ravindran wr715 MM Year 3 Clinical Skills Day
31/03/19
Thyroid exam
Wishvan Ravindran
wr715

2. Overview Quick History Clinical Examination Investigations
Interpretation of results

3. Intro
Wash hands- before history, before examining patient and after examining patient.
Introduce full name and role, confirm patient’s name and DOB, offer chaperone.
Permission- state purpose of exam ‘I’ve been asked to examine your thyroid gland which will involve me checking the glands in your neck, having a look at your face, and asking you to do a few movements. Would that be ok?’
Exposure- upper ⅓rd of sternum ‘I’d need to be able to see just below your neck’
Reposition- ensure there’s space behind the chair, could ask patient to move chair forward.

4. History Establish PC - SOCRATES, effect on patient’s life.
Previous episodes, precipitants/exacerbating factors, alleviating factors
Exclude/Establish: - Psychiatric symptoms: mood swings, depression, concentration
- Hypo/Hyperthyroid symptoms: weight changes, appetite, constipation, cold intolerance, menstrual irregularities
- Anaemia: fatigue, breathlessness on exertion
- Diabetes: polyuria, polydipsia, infections
- Chronic infection, local malignancy symptoms: FLAWS, anorexia
PMH, FH- psychiatric illness, thyroid problems, autoimmune conditions- T1DM
SH, DH+allergies, ICE
weight changes
appetite
fatigue
PC could be any of these symptoms, but most likely weight changes, tiredness, appetite changes, cold intolerance.

5. Examination *Wash hands again* General inspection:
Sweaty/inappropriate clothing for weather
Agitated, hyperactive, tremors, anxious
Hoarse voice? (thyroid enlargement compressing recurrent laryngeal nerve)
Walking aids- proximal myopathy
Hands:
Dry/Sweaty hands
Palmar erythema
Thyroid acropachy: phalangeal bone overgrowth and soft tissue swelling associated with Grave’s autoantibodies
Thyroid acropachy
Onycholysis
Tremor
Pulse (15s)- brady/tachy/irregular

6. Examination Eyes: Loss of outer ⅓rd of eyebrows
Exophthalmos- examine eyes from front, sides and above (back)
Ophthalmoplegia - H test keeping head still.
- Ask if any pain/double vision before AND after H test.
Lid lag- move finger downwards, upper eyelids will lag
Mouth:
Inspect for undescended thyroid, thyroglossal cyst or lingual goitre at back of tongue.
(protrude tongue and say aah)
Exophthalmos: looking for lid retraction (whether sclera visible above iris), inflammation of conjunctiva. Caused by abnormal connective tissue deposition behind eyes.
Ophthalmoplegia- look for any restriction of eye movement
Lid lag is associated with symp overactivity
Thyroglossal cyst: birth defect- fibrous cyst formed from persistent thyroglossal duct.
Lingual goitre: tumour at back of tongue formed by enlargement of embryonic remnant.

7. Examination
Neck:
Closer inspection from front AND side- goitre, thyroidectomy scars
Ask patient to protrude tongue, then swallow a sip of water, while observing thyroid.
Palpation - From BEHIND.
- Ask about pain, warn that might be uncomfortable.
- Palpate left and right thyroid lobes.
- Palpating thyroid bilaterally, repeat tongue protrusion + swallowing.
- Palpate cervical lymph nodes. Firm nodes near a goitre suggests malignancy
Tracheal deviation- could be caused by large thyroid mass (warn discomfort)
Make it obvious that you’re looking at the thyroid in particular.
Thyroglossal cyst would move upwards on protruding tongue.
A goitre would move upwards on swallowing, unless v large/fixed to underlying tissues by cancer.
Could have diffuse tenderness in viral thyroiditis.

8. Examination
Neck:
Percussion- downwards from sternal notch. Dullness indicates retrosternal goitre.
Auscultation - With bell of stethoscope, right and left thyroid lobes.
- Bruit indicates abnormal vascularity (feature of Grave’s)
Special tests - Pretibial myxoedema: non-pitting oedema (no indentation)
- Proximal myopathy: cross arms and stand up. Proximal muscle wasting
- Pemberton’s sign: raise hands above head. Facial venous congestion
- Reflex (calcaneal/biceps): Hyporeflexia/Hyperreflexia
Thank patient, wash hands and present findings to examiner.
Proximal myopathy: Excess thyroxine stimulated degradation of muscles fibres at the motor end plates of neuromuscular junctions.
Pemberton’s sign: Venous vasculature of thoracic inlet can get compressed against a large goitre when arms are raised, causing SVC obstruction resulting in a plethoric red face.

9. Investigations To complete my exam I would like to:
Take a full Thyroid-focussed History
Thyroid Function Test (TFTs: TSH, T3/fT3, T4/fT4)
12-lead ECG
(Further imaging e.g radioisotope uptake/ultrasound scan)
(anti-TPO autoantibodies)

10. TFT interpretation
Check name, DOB, NHS number of patient, date of test results.
Primary hypothyroidism:
Secondary hypothyroidism:
Hyperthyroidism:
TSH↑ fT3↓ fT4↓
TSH↓or normal fT3↓ fT4↓
TSH↓ fT3↑ fT4↑

11. NOTE
A goitre is just an enlargement of the thyroid – patient can still be euthyroid

13. Thank you!! Please do quick feedback before you leave:
bit.ly/muslimmedics
Any qs: