The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

Thyroid Exam

In addition to attending as an endocrinologist, Dr. Neil Gesundheit is an Associate Dean for Advising. He has published extensively on both medical student education and clinical endocrinology. In the following page, Dr. Gesundheit provides a few pearls on clinical evaluation of the thyroid.

 

Introduction: Too often when people are feeling for the thyroid, their fingers are nowhere near the thyroid gland.  The thyroid cartilage, despite its name, is not where the gland is situated.

It is important to observe the patient from the front, to look for swelling, to see if it moves when they swallow and to look for ancillary signs, but in this session the emphasis is on anatomy, landmarks, and palpating in the right locale.

Technique:

Clinical Pearl: most North American patients have small thyroids–15-20 gm in weight–and thus closer to the midline than might be suggested by the lateral placement of fingers in the video. For such patients, if palpating from behind, to place index and middle fingers only 2-3cm apart (off the midline). If fingers are too lateral, they might not detect the contours of the average North American thyroid.

-Neil Gesundheit, MD

YOU MUST KNOW YOUR ANATOMY AND LANDMARKS TO GET YOUR FINGERS IN THE RIGHT SPOT

Do this on yourself to be sure you have landmarks:

  • Put your finger on tip of your chin (mentalis).
  • Slide finger down the midline and the first hard structure you hit is the top of the thyroid cartilage.
  • (Surprisingly, one does not feel the hyoid bone in the midline, although sometimes its lateral end is misidentified as a hard lymphnode).
  • Run your finger down the prow or the free edge of the thyroid cartilage.
  • The next thing you hit is the cricoid cartilage (and see if you can get your fingernail in between the thyroid and cricoid cartilage–that is the cricothyroid membrane which is where trans-tracheal aspirations for pneumonia are performed).
  • Below the cricoid ring are the first two rings of the trachea, and the ISTHMUS of the thyroid overlies those two rings.
  • Ask patient to flex neck slightly forward and relax.
  • Go through the landmarks as above.
  • Place first two digits of both hands just below cricoid cartilage so that left and right fingers meet on the patient’s midline. Place thumbs posterior to patient’s neck and flatten all fingers against the neck.
    • Use finger pads, not tips, to palpate.
    • Identify the isthmus.
  • Gently draw fingers laterally 1-2cm.
    • Gently palpate lateral lobes.
  • NOW ask patient to swallow.
    • Assess for asymmetrical elevation of lobes (suggests nodularity).
  • When you are done with above, move to next phase, which is displacing  the soft tissues on one side to the midline while assessing for size with the other hand. Repeat in opposite direction.

Findings:

Thyroid Enlargement:

Diffuse Enlargement: isthmus and lateral lobes, no nodules. Grave’s, Hashimoto’s, endemic goiter, other.

Singular node: Cyst, benign tumor, false positive (only one nodule of multinodular goiter detected). Elevates index of suspicion for malignancy.

  • Assess for risk factors: radiation exposure, hardness, rapid growth, fixation to surrounding tissue, cervical LAD, male, others.

Multinodular Goiter:

Soft in Graves Disease and may have bruit.

Firm in Hashimoto’s Thyroiditis, malignancy, & benign and malignant nodules.

Tender in thyroiditis.

Systolic or continuous bruit may be heard over lateral lobes in hyperthryoidism.

[Adapted from Bates’ Guide to Physical Examination and History Taking, 9th Edition. Pages 198-200, 239]

Further Reading: The Rational Clinical Exam: Summary of Does This Patient Have a Goiter?” Siminoski K. JAMA. 1995 Mar 8;273(10):813-7.

Embedded Videos & Links (Not produced by Stanford, click through for credit and source).

Excellent and detailed page on thyroid exam, diagnosis of thyroid, disease, and approach to treatment via the University of Washington Dept of Medicine.

Thyroid–toxic signs






Advertisements

Written by stanford25admin

June 7, 2010 at 2:34 pm

%d bloggers like this: