Clinical Rounds
By
Thyroid Examination
To approach any case you have to;
1. Take History …82%
2. Do Examination…9%
Then ask yourself
3.
4.
5.
6.
7.
what is the possible diagnosis (Dx)
Differential diagnosis (DDx)
Investigations…9%
Treatment lines
Prognosis
I-
History Taking; you have to introduce yourself to the patient ( your name
& your role in the team)
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Personal history
Complaint
Present history
System review
Past history
Family history
Social history
Occupational history
(a)
Personal history;
-name
Saied is a 45 y/o farmer
-age
from Benha, married and
-sex
has 3 children the last
-occupation
one is 6 y/o and he is
smoker.
-residence
-marital status
-special habits
-date of admission (if admitted)
(b)
Complaint and its duration;
You have to ask the patient an open Q i.e.
Give the patient the chance to express his complaint without interruption
(c)
Present history (Analysis of the complaint)
i. Onset, Course, Duration
ii. Modifying factors
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What make symptoms worse?
What make it better?
iii- Related symptoms i.e. (symptoms arising from the swelling)
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pain
cosmetic appearance
dyspnea
dysphagia
fainting attacks
hoarseness of voice
Horner’s syndrome
iv- Associated symptoms i.e.( symptoms arising from other systems)
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Eye symptoms i.e. double vision, eye protrusion
Tachycardia
Loss weight in spite of good appetite
Dyspnea at rest….etc.
v- How it affects his/her life
vi- Relevant medical history
-
Previous operation
Previous or current medication
Previous radioiodine therapy
Previous investigations
Previous medical advice
(d)
System review;
iCNS
ii- CVS
iii- Resp. System
iv- GIT
v- GUS
vi- Musclo-skeletal
Don’t forget in women ask about menstrual and obstetric details
(e) Past history;
iHospital admission
ii- Operations
GA or LA
iii- Drugs
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iv-
Diseases
-
vvi-
Oral hypoglycaemic & Insulin
Oral contraceptive pills (OCP)
Oral anti-coagulant & Heparin
Other drugs
antiepileptic, antiheart failure
D.M
Hypertension
IHD
Renal impairment
jaundice
Allergy
Accident
Atopy & Drugs
(f)
Social history;
1- Special habits
2- Help
(g)
smoking, alcohol..etc.
by other family members
Family history;
1- Similar disease
2- Death of 1st degree relative during surgery
(h)
Occupational history;
1- Current job
2- All previous jobs
II-
Examination ; you have to ask the patient for his permission before touching him
1- General examination; the relevant systems to be examined include
the cardiorespiratory system and the lower limbs
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Pulse
rate, rhythm, water hummer pulse
Look for signs of heart failure
Inspect the shins for pretibial myxedema
Test for proximal myopathy
Test for reflexes
2- Local examination;
TIPS
 Push the seat away from the wall
 Render the water to the patient by yourself
 Exposure down to both clavicles
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Inspection
Palpation.
Percussion
Auscultation
- Trachea
- Esophagus
- RLN
-Eyes
- Hands
 Inspection; from front
- At rest…site, size, surface, shape, skin over
- On swallowing
- On protrusion of the tongue
 Palpation; From front (3T)
- Temperature, Tenderness and Trachea
From behind
- repeat the swallowing and protrusion test
- palpate 2 lobes and isthmus
- palpate upper pole for thrill and lower pole for
retrosternal extension
- palpate the carotid pulse
- palpate the cervical L.Ns using up and down technique
N.B; - To do the swallowing test ask the patient to take a sip of water, hold it
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in the mouth and swallow when you indicate
To do protrusion test you have to support the lower jaw
 Percussion; from the front
Percuss over the sternum from the notch downwards listening for a change in the
percussion note if there is retrosternal extension
 Auscultation; from the front
Listen over the thyroid for systolic bruit
 Gently palpate the trachea for deviation by placing one finger over the trachea.
It should lie equidistant between the heads of the clavicle.
 Ask the patient if she/he has had any problems swallowing.
 Ask the patient if she/he has noticed any change of voice
 Ask the patient to repeat a sentence that you read in order to listen to the
hoarse voice.
This includes examination of the hands and eyes
1- Hands
 Increased sweating
 Palmar erythema
 Thyroid acropachy
 Fine tremors
 Pulse
tachycardia, water hummer pulse
2- Eyes; 4 groups
1- Lid retraction
i.e. Dalrymple’s
sign
2- Lid lag i.e. Von
Grafe’s sign
3- Infrequent
blinking
i.e.Stellwag’s
sign
1- Sclera is seen
below the
inferior limbus
2- Sclera is seen
all around the
cornea
3- Nafziger test
for proptosis
4- Lack of
convergence
(Mobius’ sign)
5- Lack of
forehead
wrinkling
(Joffroy’s sign)
6- Corneal
ulceration
Ask the patient to look up
and out to test for the
integrity of the superior
rectus and inferior oblique
Edema of the
conjunctiva with or
without redness
Assessment sheet
Elements being
assessed
1- Introduction to
the patient
2- Adequate
exposure
3- Observing neck
from front
4- Observing
swallowing and
protrusion of
the tongue
5- Palpating neck
from behind
6- Checking for
cervical L.Ns
7- Percussion and
Auscultation
from front
8- Thyroid status
9- Thanking the
patient and
washing hand
Done well
2
Done adequately
1
Not done
zero