- Wash hands, check right patient, introduce yourself, get permission
- Ask the patient to sit up straight in a chair, and expose their neck down to the shoulders. You could ask them to look up a little bit. Remove any jewellery.
- Lethargic, disinterested
- Bradycardia (radial pulse)
- Sweaty – hyperthyroidism
- Palmar erythema
- General warmth
- Thyroid acropachy – can cause swelling (perhaps clubbing) in the extremeties as a result of periosteal new bone formation as a result of Grave’s disease.
- Onycholysis – painless separation of the nail from the nail bed – present in autoimmune thyroid disease (so can be hyperthyroid and hypothyroid?)
- Tremor – place a piece of paper on the back of the hands and watch for tremor.
- Tachycardia, and possibly irregular pulse. Patients with hyperthyroidism can have an irregular pulse as a result of atrial fibrillation. Hypothyroid patients have a very slow pulse.
- Pre-tibial myxedema – can be found anywhere on the body, but often on the shins – a plaque-like thickening of the skin caused by Grave’s disease.
- Night sweats
Inspect and palpate the face
Look for signs of hyperthyroidism (remember these only occur in Grave’s disease)
- Lid lag – this is where the eye-lid will not move as quickly as the eye downwards when the patient looks downwards.
- General discomfort of eyes, oedema, grittiness
Look for signs of hypothyroidism
- Dry hair
- Dry skin (waxy skin)
- Puffy eyes
- ‘peaches and cream complexion’
- Deep voice
- Cold intolerance
- Loss of the outer parts of the eyebrows.
- Etc etc
Asymmetry and swelling – get the patient to tilt their head upwards – look for obvious signs of goitre, lumps and swelling. If you see any swelling (particularly in the midline), then ask to patient to stick out their tongue – if the swelling rises, then it is likely to be a thyroglossal cyst. This forms in a remnant of the thyroglossal duct (down which the thyroid travels during development). It normally closes off, but in some people it can remain, and can become fluid filled to make a cyst. A thyroglossal cyst will also move on swallowing. The thyroglossal duct is attached to the hyoid bone.
Swallowing – have a glass of water handy! Ask the patient to swallow – normally this will elevate the larynx – and watch out for any other lumps moving:
- The thyroid will ALWAYS elevate (if it is normal or abnormal).
- Anything attached to the cricoid cartilage will also move on swallowing
- Lymph nodes will probably not move on swallowing.
- Anything not attached to the thyroid or cricoid – lipoma, carotid body tumour, epidermal cyst.
You should do this from behind – to allow a better feeling of the lumps and greater control of the fingers. You should use both hands at the same time to compare left and right sides. Be gentle because it will probably be uncomfortable for the patient. Ask if they have any pain and explain what you are going to do.
Identify the cricoid cartilage. Then palpate for masses first in the anterior triangle, then in the posterior triangle. Remember to check all the way down to the clavicles, and as far posteriorly as the trapezius. If you find a lump you should note its:
- Consistency – soft masses will tend to be fluid filled, and will often be lymph nodes. Hard nodular masses may be malignancy. Hard smooth masses may be enlarged organs or tissues
- Mobility – fixed masses are more likely to be malignant, and benign masses more likely to be mobile.
- Tenderness – a tender mass is more likely to be an acute infection or inflammatory problem.
- Translumination may be of help to determine fluid filled lesions – which will transluminate.
- Pulsation – nothing should do this except the carotid – if a swelling does do this then it could be a carotid body tumour (chemodectoma).
Feeling specifically for the thyroid – it is not always that easy to feel. Start at the laryngeal prominence and move down to find the cricoid cartilage. The isthmus of the thyroid covers the 2nd, 3rd and 4th tracheal cartilages, so try and feel this. Then try and feel the lobes of the thyroid. You can always ask the patient t swallow some water as you do this so you can feel for movement of the thyroid. The lobes should be roughly no bigger than the patient’s thumb. The normal thyroid is often not palpable – the lobes could be tucked under SCM. Things of particular note are any lumps, and any irregularity between the two lobes.
Feeling for the lymph nodes – use a logical sequence! You should include:
- Posterior auricular
- Cervical chain
- Posterior cervical chain
Auscultate the swelling
- USS – find out if lump is solid or cystic
- Radioactive iodine to detect if nodule is hot or cold (if it is cold more likely to be malignant).
- Check reflexes – hyperthyroidism – hyperreflexia, hypothyroidism – hyporeflexia. In hypothyroidism, the ankle reflex is particularly delayed.
- Proximal myopathy in hyperthyroidism – ask the patient to put out their arms and then you try to push them down – if it easy to push the arms down, it suggests proximal myopathy.