Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Goitre |
Graves’ disease |
RF: Young-middle aged women, family history & smoking.
Universal hyperthyroid symptoms: sweating, tachycardia, anxiety, weight loss, fatigue, insomnia, loose stool, heat intolerance. Graves’ specific symptoms: exophthalmos, ophthalmoplegia, pretibial myxoedema, thyroid acropachy. Diffuse goitre – entire thyroid glad is enlarged and smooth. |
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Toxic multinodular goitre |
Common in older patients >50 years.
Symptoms of hyperthyroidism as above. Multinodular goitre – entire thyroid gland enlarged but usually asymmetrical & lumpy feeling. |
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Solitary thyroid nodule |
Symptoms of hyperthyroidism as above.
Goitre – palpable uninodular enlargement. |
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Subacute (De Quervain’s) thyroiditis |
RF: Recent viral URTI, may develop postpartum.
Symptoms of hyperthyroidism plus fever, neck/jaw pain. Goitre – large, firm, tender, smooth in thyrotoxic phase. |
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Hashimoto’s thyroiditis |
RF: Young-middle aged women, family hx, autoimmune hx.
Hypothyroid symptoms: fatigue, weight gain, dry skin, hair loss, oedema, menorrhagia, constipation. Goitre – transient smooth, diffuse goitre followed by atrophy. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient sitting | ||
| Appropriate exposure of neck | ||
| General Inspection | Systemic appearance | |
| Body habitus | ||
| Appropriate clothing | ||
| Obvious tremor | ||
| Gross neck swelling | ||
| Clues in bed space | ||
| Hands | Tremor | |
| Temperature | ||
| Finger clubbing (thyroid acropachy) | ||
| Palmar erythema | ||
| Radial pulse | ||
| Face | Colour | |
| Skin | ||
| Hair | ||
| Eyebrows | ||
| Eyes | Look from anterior/lateral & from above | |
| Lid retraction | ||
| Exopthalmos | ||
| Lid lag | ||
| Ophthalmoplegia | ||
| Neck Inspection | Look from anterior/lateral aspect | |
| Goitre | ||
| Ask to swallow | ||
| Ask to stick out tongue | ||
| Neck Palpation | Palpation from posterior | |
| Check for pain prior to palpation | ||
| Palpation of thyroid gland | ||
| Evaluation of lump/swelling | ||
| Palpation whilst swallowing | ||
| Palpation whilst sticking out tongue | ||
| Presence of thrill | ||
| Palpation of cervical lymph nodes | ||
| Tracheal position | ||
| Percussion | Percuss for retrosternal goitre | |
| Auscultation | Thyroid bruits | |
| Legs | Pretibial myxoedema | |
| Reflexes | ||
| Special Tests | Pemberton’s test | |
| Proximal myopathy | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to carry out a thyroid examination. This involves looking at and feeling the thyroid gland in your neck. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient sitting on a chair, ensuring you have space to walk around and stand behind the patient during parts of the examination. Ensure the patient’s neck is adequately exposed (e.g., Top button undone).
General Inspection
Look at the patient and around the bed space for useful signs:
- Systemic appearance – does their appearance indicate hyperthyroidism (flushed, sweaty, restless) or hypothyroidism (flat affect, limp hair, slow speech, shivering)
- Body habitus – weight loss is a symptom of thyrotoxicosis; weight gain seen in hypothyroidism
- Appropriate clothing – is the patient dressed appropriately for the weather and surroundings? Multiple layers in a warm setting indicates hypothyroidism; minimal clothing in cold setting indicates thyrotoxicosis
- Obvious tremor (e.g., Fine tremor of hyperthyroidism)
- Gross neck swelling (e.g., Goitre visible from the end of the bed)
- Clues around the bed space (e.g., Extra clothes, fans, walking aids, medications, cigarettes)
Hands
Examine both hands together noting:
- Tremor – fine tremor seen in hyperthyroidism; if subtle, it can be accentuated by placing a piece of paper on top of the outstretched hands
- Temperature (e.g., hot sweaty palms in hyperthyroidism; cold hands and dry skin in hypothyroidism)
- Palmar erythema
- Finger clubbing (thyroid acropachy) – associated with Graves’ disease
- Radial pulse – assess rate; elevated resting pulse rate commonly seen in hyperthyroidism
Face
Look at the patient’s face, noting the colour (e.g., Any facial flushing seen in hyperthyroidism), any dry skin (hypothyroidism) and evidence of hair loss from scalp/outer 3rd of eyebrows (hypothyroidism).
Eyes
Inspect the eyes from anterior and lateral aspects as well as from above the patient’s head to look for signs of thyroid eye disease (hyperthyroidism).
Signs of thyroid eye disease are:
- Lid–retraction
- Lid–lag
- Exophthalmos
- Ophthalmoplegia
Signs of non–specific thyroid eye disease include lid retraction (increase in proportion of white sclera seen between eyelid and iris) and lid–lag. To test for the latter ask the patient to look upwards ands focus on your finger, then to follow your finger as you move it downwards; if lid-lag is present gaze will move downward faster than the upper lid.
Graves’ disease specific eye signs include exophthalmos (protrusion of the eyes bilaterally from the head) and ophthalmoplegia (weakness or paralysis of oculomotor muscles). To test for the latter, perform the ‘H’ test by asking the patient to follow your finger with their eyes keeping their head still whilst you move your finger up, down, left and right to check their eye movements in all directions. Ophthalmoplegia will cause diplopia especially of upward gaze.
Neck Inspection
Look at the patient’s neck from both the anterior and lateral aspects. Look for any midline swelling which may indicate a goitre.
Ask the patient to swallow a sip of water; a thyroid lump or swelling will move with the thyroid gland when the patient swallows. Then ask the patient to stick their tongue out; a lump or swelling which moves with tongue protrusion indicates a thyroglossal cyst.
Neck Palpation
To palpate the neck, including the thyroid gland, move to stand behind the patient. Use the pads of your fingers of both hands to examine the midline of the neck. Ask the patient to slightly flex the neck and check for pain before you begin palpation.
Palpate the thyroid cartilage, the first prominent structure in the midline of the neck, starting from the chin. Move your hands downward to the next midline prominence, the cricoid cartilage. Just below the cricoid cartilage is the thyroid isthmus, with the lobes of the gland sitting just laterally on either side.
If a thyroid lump or swelling (goitre) is present, evaluate the size, consistency, tenderness, and mobility. Is the lump diffuse (involving the entire thyroid)) or nodular (localised)? Does the thyroid feel smooth or lumpy (nodular)? Feel for any palpable thrills over the thyroid.
Palpate the thyroid whilst asking the patient to swallow a sip of water; a lump that moves during swallowing suggests a goitre. Palpate the thyroid while asking the patient to stick their tongue out; a lump that moves indicates a thyroglossal cyst.
Finally, palpate for cervical lymphadenopathy and assess the position of the trachea (e.g., central or deviated).
Percussion
Percuss downward from the sternal notch toward the xiphisternum. Persistent dullness upon percussion may indicate a retrosternal goitre.
Auscultation
Using your stethoscope, listen over both lobes of the thyroid for bruits (present in Graves’ disease).
Legs
Examine the patient’s legs for:
- Pre–tibial myxoedema – peripheral oedema associated with Graves’ disease
- Brisk knee–jerk reflexes – seen in hyperthyroidism
Special Tests
Special tests in thyroid examination are:
- Proximal myopathy – ask the patient to stand up from the chair without pushing up with their arms. Inability to do suggests proximal thigh muscle weakness, which is seen in hyperthyroidism
- Pemberton’s test – ask the patient to raise both arms. Observe for facial plethora and breathlessness, which may indicate a large goitre obstruction venous return.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the thyroid examination findings, you may wish to carry out further investigations, including thyroid function blood tests, thyroid antibody tests, or further imaging (e.g., thyroid ultrasound scan).
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Last updated Dec 2024
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