Thyroid Exam

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