Thyroid history and physical

examination

Dr. Anas Aljundi

Teaching Assistant – Alquds University
07/04/2020
 Thyroid History
• Two groups of symptoms:
1- Local symptoms: Hx of lump
and other local symptoms

2- Endocrine symptoms:
Hx of hyper/hypo thyroidosim
symptoms.
 Local Symptoms
1- A lump in the neck:
- Mostly painless and slowing.
- Rapidly enlarged and painful
could be due to:
1- Hemorrhage into a necrotic nodule
2- Fast growing carcinoma: anaplastic
carcinoma
3- Subacute thyroiditis
 Local Symptoms
2- Discomfort during swallowing:
- Tugging sensation; not true dysphagia:
• Esophagus is a muscular tube so rarely
be obstructed.
• An enlarged gland make the upward
movements with the trachea
uncomfortable and difficult.
 Local Symptoms
3- Dyspnea
- A positional dyspnea
• Is worse during flexion of the neck or
during supine.
• May cause stridor ( a whistling sound
during inspiration if trachea is
compressed). positive kocher test
 Local Symptoms
4- Hoarseness:
• Change in quality of the voice with
the lump in the neck.
• Probably caused by paralysis of one of
the recurrent laryngeal nerve.
• Means the lump is likely to be
malignant ( infiltrating the nerve )
 Review of innervation
- The intrinsic muscles of the larynx are supplied as the following:
 Review of innervation
- If superior laryngeal branch is involved:
Paralysis of cricothyroid muscle + anesthesia of the
larynx above the vocal cords:
1- Weak voice with decreased pitch ( loss of high-pitch
sound )
2- Occasional aspiration
- If Recurrent laryngeal nerve is involved:
Paralysis of all the intrinsic muscles ( except
cricothyroid ) + anesthesia of the larynx below
vocal cords:
Unilateral: hoarseness
Bilateral: Stridor and respiratory distress. ( why)?
 Endocrine Symptoms ( Hyperthyroidism )
1- Nervous System:
• Nervousness and irritability.
• Anxiety
• Insomnia
• Mania
• Headache and tremor of the hands and
tongue.
• Eyes movement are difficult; eyes
become more protuberant. Difficulty
closing their eyes. Double vision.
 Endocrine Symptoms ( Hypothyroidism )
1- Nervous System:
• Slow thought, speech and action.

• Hallucinations or dementia ( myxedema

madness ).

• Depression

• Myxedema coma: in sever cases.

 Endocrine Symptoms ( Hyperthyroidism )
2- Cardiovascular:
• Palpitations: atrial fibrillation/
extrasystoles
AF: maybe the only finding in an elderly patient!

• Breathlessness on exertion

• Chest pain

• Ankle swelling
 Endocrine Symptoms ( Hypothyroidism )
2- Cardiovascular:
Symptoms of heart failure:

• Breathlessness ( or due to pleural

effusion )

• Ankle swelling
 Endocrine Symptoms ( Hyperthyroidism )
3- Metabolic and Alimentary:
• Loss of weight despite increase in
appetite

• Diarrhea

• Heat-intolerance

• Excessive sweating
 Endocrine Symptoms ( Hypothyroidism )
3- Metabolic and Alimentary:
• Weight-gain despite poor appetite

• Tiredness and weakness

• Cold-intolerance

• Constipation
 Endocrine Symptoms ( Hyperthyroidism )
4- Musculoskeletal and genital tract:
• Muscle weakness: especially proximal
muscles.

• Decrease quantity of menses or even

amenorrhea
 Endocrine Symptoms ( Hypothyroidism )
4- Musculoskeletal and genital tract:
• Muscle weakness: especially proximal
muscles.

• Menorrhagia

• Infertility and decreased libido.

 Other Aspects of Hx
1- Age:
- Hyperthyroidism:
• Primary thyrotoxicosis: young women between
15-45 years.

• Toxic goiter: any age.

• Secondary thyrotoxicosis ( multinodular goiter ):

middle age between 45-65 years.

- Hypothyroidism:
In middle and old age.
 Other Aspects of Hx
2- Gender:
- Hyperthyroidism:
• Primary thyrotoxicosis: 10 times
more in females than males

- Hypothyroidism:
More common in females
 Other Aspects of Hx
3- Drug, family and social hx:
- Drug: amiodarone or antithyroid
drugs.

- Family history: of thyroid or

autoimmune disease

- Social history: Living in areas of iodine

deficiency: Central Africa, Himalaya
 Examination of the thyroid
• Examination of the glad itself ( neck
examination )

• Examination for endocrine activity.

 General Things
General things to do in every examination:
1- Greeting

2- Introduce yourself

3- Take PERMISSION

4- Make sure there’s PRIVACY

5- Good light and wash your hands ( high-gel)

 Look at the whole patient
ABCDE:
• A: Appearance of the patient:
does he look agitated and constantly moving? Or are they
slow in their movement and apathy?
• B: Body-built of the patient:
Over-weight or under-weight ?
• C: Consciousness/Color/Clothes?
Oriented ( place, person and time? ); color: blue-gray color (
taking amiodarone ). Over-clothes despite hot weather?
Under-clothes despite cold weather?
• D: Decubitus:
Sitting comfortably?
• E: Environment:
Does he connected to cannula? Cardiac monitoring etc…?
 Look at the HANDS
• Examine both hands together, inspect the dorsal
then palmar aspect of both hands, and look for:
1- Sweaty/Warm?
or Dry/Cold?
2- Clubbing:
thyroid acropachy

3-Onycholysis:
hyper/hypothyroidism.
 Look at the HANDS
4- Palmar Erythema

5- Pallor of palmar crease:

anemia can be in hypothyroidism

6- Tremor: -
fine and fast tremor.
 Look at the HANDS
7- Muscle wasting:
hyperthyroidism

8- Puffy hands:
hypothyroidism
9- Carpel tunnel syndrome:

hypothyroidism
 Don't Forget VITAL SIGNS
• 1- Pulse: Rhythm? Rate? Volume?
- Hyperthyroidism: Tachycardia/Irregular
Rhythm ( AF )/High-volume
- Hypothyroidism:
Bradycardia
• 2- Respiratory Rate:
can be increased in hyperthyroidism.
• 3- Blood Pressure:
- Increased in hyperthyroidism
- Decreased in hypothyroidism ( always? )
• 4- Temperature:
- Increased in hyperthyroidism
- Decreased in in hypothyroidism
 Examine the FACE
1- Muscle wasting of the face:
hyperthyroidism
2- Periorbital edema/loss of
outer third of eyebrows:
hypothyroidism

3- Peaches and cream

complexion:
hypothyroidism
 Examine the EYE
1- Eyes: - Jaundice
- Pallor of Conjunctiva

2- Thyroid Eye disease:

 Thyroid Eye disease
1- Lid lag and lid retraction
 Thyroid Eye disease
2- Exophthalmos
 Thyroid Eye disease
Exophthalmos vs Lid retraction:
 Thyroid Eye disease
3- Ophthalmoplegia
 Thyroid Eye disease
4- Chemosis

Examine the mouth?

Hypothyroidism Hyperthyroidism
 - Position: Sitting on chair
Neck Examination - Exposure: All over the neck

1- Inspect the neck:

- Site: muscular triangle.
- Ask him to swallow ( may need a sip of water to
help for swallowing ). All thyroid swellings ascend
during swallowing ( why? )
- Ask him to open his mouth and put out of his
tongue: thyroglossal cyst.

- Skin:
- Scars?
- Redness?
- Puckered or tethered ( advanced
carcinoma anaplastic carcinoma )?
- Distended neck veins?
 Neck Examination
2- Palpate the neck from front:
- To confirm your visual impression of size and
shape.
- Examine for 3T's:
1- Tenderness
2- Temperature: compare
3- Position of trachea: best done by feeling
with the tip of two fingers in the suprasternal
notch ( should be exactly central at this point).
>> If thyroid obscures the trachea: here
examine the thyroid cartilage ( a mass
displacing the trachea with tilt the thyroid
cartilage laterally ).
 Neck Examination
3- Palpate the neck from behind:
- Stands behind the patient and tilt the patient's
head slightly forward to relax the anterior neck
muscles.
- Use your palmar surfaces to rest on each side of
neck.
- Ask the patient to swallow to confirm it's thyroid.
- Are you able to feel the lower border of the gland (
or significant retrosternal goiter? )
- You can palpate each lobe individually; by pressing
firmly to opposite side of the neck to make it
prominent and easier to feel.
- At the end of palpation; you should know:
tenderness, shape, size, surface and consistency.
- LASTLY: palpate the whole of the neck for any
 Neck Examination
4- Percussion:

5- Auscultation:
 Neck Examination
6- Pemberton Sign
- To evaluate venous obstruction in patients
with goiters. The sign is positive when
bilateral arm elevation causes facial plethora.
- Resulting from the thyroid obstructing the
thoracic inlet, thereby increasing pressure on
the venous system
 Other General Examination
1- Cardiorespiratory examination:
- Auscultate the chest for pulmonary edema.
( Heart Failure )

- Pleural effusion in case of hypothyroidism.

 Other General Examination
2- Examine the lower limbs:
- For ankle edema ( Heart Failure )
 Other General Examination
3- Neurological examination:

- For proximal myopathy.

- For reflexes:
• Hyperthyroidism: hyperreflexia
• Hypothyroidism: sluggish and
relaxation period prolonged (
delayed relaxation time )
Summary
DDx of goiter
 Other type of thyroiditis

- Caused by fibrosis of thyroid gland ( painless

)