Examination Of a Patient with Thyroid Disease
1- General examination:
- General appearance - Vital signs
- Eyes signes in thyroid disease - Examination of the lower limb
2- Local examination of the neck and the thyroid gland 3- Examination of other systems as CVS,CNS...
1- General examination
A) Examine the patient for general signs of hyper or hypothyrodism as irritability, nervousness, swetting...
B) Examine the hand for signes of hyper or hypothyrodism as fine tremor ( by paper test ), sweeting, palmar erythema, onycholysis ( in hyperthyrodism, separation of the nail from the nail bed ).
C) Examine the pulse for tachycardia or irreguler irregular pulse (atrial fibrilation) in hyperthyrodism and Bradycardia in hypothyrodism.
D) Examine the face for loss of the hair in the outer part of the eye borrow and mask face in hypothyrodism.
E) Examine the eye for signs of hyperthyrodism as :
1- Expophthalmus ( protrosin of the eye ball) by :
Paper test, hold the paper in front of the eye, normaly it will not touch the cornia, if it touch it, it is abnormal ( take care not to harm the patient ).
Look from the above of the patient`s head, normaly you can not see the cornia and scelera, if you see it, it is abnormal.
Ask the patient to look for the roof of the room while you are holding his head in straight position, normaly the patient has to do wrinkeling of the skin of the foreheah, if he can look to the roof of the room without wrinkeling of the skin of the foreheah, it is abnormaly.
2- Ophthalmoplagia ( paralysis of one or more of the eye muscles )
- all the muscles of the eye supplied by oculomotor nerve except superior obliqus muscle supplied by trochlar nerve, and lateral rectus muscle supplied by abducen nerve. Hold the head of the patient straight by putting your left hand on his head, put your right indix finger at resonable distance, examin all the movment of the eye. The most common nerve to be
affected in hyperthyrodism is abducen nerve.
3- Lid lag
( Hold the head of the patient straight by putting your left hand on his head, put your right indix finger at resonable distance, ask the patient to follow your finger from above to down word, normaly, the upper eye lid will follow the cornia so you can not see the sclera, if you can see the sclera between the upper eye lid and the cornia during the movment, this is abnormal )
4- Lid retraction
( Hold the head of the patient straight by putting your left hand on his head, ask him to look at fixed point in the wall of the room, normaly, the upper eye lid is covering the upper margin of the cornia so you can not see the sclera, if you can see the sclera between the upper eye lid and the cornia, this is abnormal )
5- Chymosis
( reddness and sweling of the conjonctiva, odema and hyperemia of the conjonctiva )
F) Examine the lower limb for the reflexes -hyper reflexia in hyperthyrodism
-hypo reflexia in hypothyrodism
-G) Examine the lower limbs for peritibial myxodema
( it is non pitting odema, ranging for mild odema to peut d`orange appearance, it is due to diposition of mucoplysaccarieds in Grave`s disease ).
E) Examine the vocal cord by direct laryngoscopie for any vocal cord paralysis.
2- Local examination of the neck and thyroid gland
Position: ask the patient to sit on chair, look from the front if there is swelling, ask him to swallow or to drink a water, if the swelling moves with the swallowing so it is a thyroid mass.
Discripe it (inspection) : the site, the skin, any scar ,
e.g,there is a mass in the right side of the neck which is moving with swallowing, the skin above it is normal, no redness or dilated vein or wound, and no scar.
- Go behind the patient and examine the thyroid and the neck with the palm of your fingers, by both hands,and the thumbs on the mastoid process (note: fix one hand and move the other, then alternate, don`t examine the thyroid or the mass by moving both hands on the same time).
Discribe the mass (palpation)
- Site, size, tendence, shape ( oval, round....), edges (well defined or ill defined), constancy ( hard, soft, firm), surface ( smooth or rough), attached to underling structure or the skin , pulstile, flactuant, any thrill, any other lumbs.
e,g : there is a mass in the right side of the thyroid about 2cm, not tender, hard inconstancy, ill defined edages, round, not attached to the skin but attached to underlining structures, rough surface, not pulstile, no other mass in the same lobe or other thyroid lobe.
Examine the cervical lymph node for any lymphadenopaty.
-the cervical lymph node groups are ( submental, submandibular, pre and post auricular, upper, middle and lower deep cervical, posterior occepital, suprascapular ).
Do percaution over the sternum ( normally it is resonant, if it is dull it meanes there is retrosternal extension ).
Auscultate over the mass for any bruie( if it present it meanes there is hyperthyrodism as in Grave`s diseas) , Ask the patient to hold his breathing for 30 sec. During
auscultation .
