Normal thyroid = 20 grams
Vitals
Inspection
- Neck (from front and sides) – goiter (look for obliteration of the medial borders of the SCM), masses, symmetry (also while swallowing – most sensitive!), venous distension
- Eyes
- Graves: proptosis, chemosis, EOM dysfunction, corneal ulcerations, optic nerve entrapment
- Thyrotoxicosis: lid lag (see white above iris), stare with decreased blink, widened palpebral fissures
- Associated conditions – Vitiligo, RA, Myasthenia gravis, DM, Pernicious anemia
Palpation
- From front or back, while swallowing (push SCM forward to get deeper)
- Carotid pulse (absence = Berry’s sign for malignant thromegaly)
- Consistency (hard = cancer/scarring, soft = toxic goiter), size, tenderness (infection or hemorrhage), homogeneous (diffuse)
- If nodule felt, feel for cervical and supraclavicular nodes (cancer)
Auscultation
- Use bell
- Thyroid bruits (abnormally large blood flow and suggests toxic goiter)
Special tests
- Pemberton’s sign: impair venous outflow from head and neck – facial suffusion with dilatation of cervical veins when arms raised and externally rotated (thoracic outlet syndrome)
- Look for presyncope, SOB, cyanosis, plethora
Signs of thyrotoxicosis include
- Nervous, agitated, labile affect
- Weight loss
- Warm, flushed, moist skin
- Onchynolysis
- Tremor
- Hyperreflexia
- Proximal muscle weakness
- Increased pulse pressure
- Tachycardia
- Systolic outflow tract murmurs
- Pretibial myxedema
Hyperthyroid:
Vitals: Tachycardia, HTN, Hyperthermia
General: Heat intolerance, Weight loss with good appetite
Eyes: Exophthalmos, Periorbital edema, Double vision, Decreased motility (weak convergence), Widened palpebral fissure, Lid Lag, Decreased blinking, Chemosis
Neck: Goitre
Cardiac: Palpitations, Peripheral edema (excessive mucopolysaccharide deposits under skin)
GI: Increased BM
GU: Polyuria, Decreased fertility
Neuromuscular: Fatigue, Weakness, Tremor
Emotional: Nervous, Irritable
Dermatologic: Hair thinning, Increased perspiration, Change in skin texture, change in pigmentation, Acropachy of nails (like clubbing), Brittle nails
Hypothyroid:
Vitals: Diastolic HTN, Hypothermia, Bradycardia
General: Cold intolerance, Weight gain with regular diet (obesity)
Eyes: Dry
GI: Constipation, Enlarged tongue
Cardiac: Fatigue
Nervous: Speech disorders, Short attention span, Tremor, Hyporeflexia (delayed relaxation – Achilles’ tendon), Defective abstract reasoning, Spasticity, Depressed affect
Musculoskeletal: Lethargy, Thick skin, Dry Skin, Alopecia, Brittle Nails, Leg cramps, Periorbital edema, Puffy facies, Queen Anne’s sign (loss of lateral 1/3 eyebrow), Hypotonia
Reproductive: Heavier menses, Decreased fertility
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