Thyroid Status Examination

Introduction

Wash your hands, introduce yourself, and ask permission (consent) to examine. Ask if the patient has any pain. Expose the neck fully (ensure you can see the top of the sternal area) and get the patient to sit on the edge of the bed or on a chair.

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Inspection

General features:

- Eyes / neck / clothing (over/under-dressed - cold/heat intolerance)
- Get the patient to speak (check the voice - is there any recurrent laryngeal nerve damage post-thyroid surgery?)
- General habitus: thin (hyperthyroid), not-so-thin (hypothyroid)

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Hands

Look and feel for:

- Sweating (hyperthyroidism)
- Tremor (hyperthyroidism)
- Temperature (warm in hyper and cool in hypothyroidism)
- Thyroid acropachy (looks like clubbing)

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Radial Pulse

Feel for:

- Tachycardia or AF (hyperthyroidism)
- Bradycardia (hypothyroidism)

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Reflexes

Test for:

- Hyper-reflexia (brisk reflexes in hyperthyroidism)
- Hypo-reflexia (slow-relaxing reflexes in hypothyroidism)

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Eyes & Face

General appearance

- Classically described 'toad-like' facies (coarsened features - seen in hypothyroidism)
- Loss of outer third of eyebrows (hypothyroidism)

Skin

- 'Peaches and cream' - rounded face, with some pink flushing (hypothyroidism)
- Thickened, coarse skin, occasionally with periorbital puffiness (hypothyroidism)

Eyes

These signs are all found with hyperthyroidism:

- Retraction
- Proptosis (look from above the head - do the eyes protrude?)
- Exophthalmos (proptosis caused specifically by endocrine disturbance - white sclera visible above and below)
- Chemosis (oedema)
- Check eye lids close
- Lid lag: Delay in eyelid descent whilst getting the patient to slowly follow gaze from high to low. Use a single finger held horizontally and make sure you move downwards slowly.
- Ophthalmoplegia (restricted eye movements) / poor convergence (move finger from far to near the patients face)

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Neck

From the front:

- Observe whilst getting the patient to swallow (ideally there will be a glass of water that you can use) & also to stick out their tounge ? does neck lump rise with these actions? If yes, then it is likely to be thyroid in origin.

From behind:

- Whilst palpating the region of the thyroid gland and the descending path (ie. down the neck), get the patient to again swallow & stick out their tongue as before. Can you feel the neck lump move up with these actions? If yes, then it is likely to be thyroid in origin.
- Palpate for local lymphadenopathy

From the front:

- Feel for tracheal deviation
- Feel the mass again (with swallow & tongue protrusion, as before). Also use this opportunity to determine the other features of the mass (see 'lumps and bumps' examination for how to describe what you find)
- Percuss to see how low down mass extends (if it goes behind the sternum then it is considered to be 'retrosternal')
- Listen for: stridor (tracheal compression) / voice change (recurrent laryngeal nerve) / bruits (can get thyroid vascular bruits)

Pemberton's sign:

- This is a sign of Superior Vena Caval (SVC) obstruction. Get the patient to raise their arms above their head and see if the veins bulge and the face becomes plethoric (features of a positive test)
- You can also test the shoulder strength for proximal myopathy at this point

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Legs

Examine:

- Pretibial myxoedema (hyperthyroidism)
- Reflexes (brisk / slow relaxing), as previously

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Extra

For some bonus points:

- You can ask the patient to cross their arms and stand from a seated position (proximal myopathy)
- Learn the signs and symptoms of hypo and hyperthyroidism that you could ask for if you were offered a few questions to ask the patient. Ask about things such as activity levels, temperature, bowel habit, mood etc.

NB. A few facts: Radio-iodine can make eye signs worse. Graves disease in smokers is more likely to have positive eye signs. Steroids can be useful in thyroid eye disease.

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