Thyroid: Examination

Thyroid: Examination

GPE

1.       Facies- Thyrotoxic facies, myxedema facies

2.       Pulse -rate and rhythm (preferably sleeping pulse)

3.       Wet/Sweaty hands

LOCAL

[A] Inspection

1.       Position and extent of the swelling

(In reference to sternomastoid muscle, suprasternal notch and thyroid cartilage)

2.       Shape

3.       Size (vertical and horizontal dimension in cms)

4.       Surface: Smooth/irregular/nodular.

5.       Margins

6.       Skin over the swelling: Scar/pigmentation/venous prominence.

7.       Any pulsation

8.       Movement of the swelling with deglutition

·         Thyroid Swelling

·         Subhyoid bursitis

·         Prelaryngeal or pretracheal lymph node

·         Any swelling arising from larynx or trachea

·         Thyroglossal cyst

9.       Movement of the swelling with protrusion of the tongue (thyroglossal cyst)

[B] Palpation

1.       Temperature /Tenderness

2.       Movement of the swelling with deglutition

3.       Movement of the swelling on protrusion of the tongue

4.       Position and extent of the swelling

5.       Shape/Size

6.       Surface, margin

7.       Consistency: Hard, firm, soft cystic, variegated

8.       Any pulsation/thrill

9.       Any skin fixity

10.   Mobility: side to side and up and down

11.   Relation of the swelling with sternocleidomastoid muscle

12.   Positions of trachea

13.   Pizzillo’s method (In obese patients with short neck)

·         Patient keeps both his hands on the occiput and extends the neck

14.   Lahey’s method

·         to palpate one lobe push swelling from opposite side e.g. To palpate the left lobe, push the right lobe to the left with the left hand so that the left lobe becomes prominent

15.   Crile’s method

·         Place pulp of the thumb over the swelling àask to swallowàswelling moves up and downà nodularity felt easily

16.   Kocher's test for tracheal compression

·         swelling is pressed slightly on either side of tracheaà stridor if tracheomalacia

17.   Berry’s sign (to look for malignant infiltration of carotid sheath)

·         Carotid pulse not palpable on the side of the swelling but palpable above and below the swelling

18.   Signs of sympathetic trunk palsy (Horner's syndrome)

(Mnemonic- AMPLE)

·         Anhidrosis (loss of sweating)

·         Miosis

·         Pseudoptosis (slight drooping of upper eyelid)

·         Loss of ciliospinal reflex

·         Enophthalmos

[C] Percussion:

·         Dull note over manubrium sterni in retrosternal goiter

[D] Auscultation

·         Any bruit audible or not near upper pole of the thyroid lobes.

[E]Examination of Cervical Lymph Nodes

EXAMINATION FOR TOXIC SIGNS

[A] Pulse

·         rate

·         rhythm

·         volume

·         any special character—collapsing or not

[B] Tremor in hands and tongue

[C] Thrill and bruit over the thyroid gland usually present at upper pole

[D]Eye signs

1.       Exophthalmos: Forward bulging of the eyeball

[Normal                        -Upper lid halfway between pupil and superior limbus

-Lower lid at a tangent to inferior limbus

Lid retraction               -Upper lid raised

-Lower lid normal

(Do not be deceived into thinking this abnormality is caused by exophthalmos.)

Exophthalmos             -Both lids moved away from centre with sclera visible below or all-round the iris]

(Norman Browse)

·         Naffziger method

§  Look from behind neck of the patient (slightly extended)à along superior orbital marginà if eyeball is seen beyond the superior orbital marginàExophthalmos present

2.       Dalrymple’s sign: Visibility of upper sclera due to spasm of upper eyelid

3.       Von Graefe’s sign: lid lag

(Mnemonic- Long neck of Giraffe causes lag in eating grass)

4.       Joffroy’s sign: Loss of wrinkling of forehead on looking up

(Mnemonic- Anger/frown of King Joffery in Game of thrones)

5.       Möbius sign: failure of convergence on accommodation at a near object from a distant object

(Mnemonic- Mobile causes failure of convergence)

6.       Stellwag’s sign: Infrequent blinking (stare look)

(Mnemonic- Still look)

7.       Chemosis

8.       Test for eye movement (any palsy)

EXAMINATION FOR RETROSTERNAL GOITRE

·         Lower margin of swelling. Whether visible or not (on deglutition)

·         Any dilated vein over the neck and chest wall

·         Pemberton's sign

§  patient raises both upper limbs above the head for 2–3 minutesà congestion and puffiness in the face with respiratory distress

·         Percussion over the manubrium sterni—Dull note