1 Inspection 69

Introduction, consent, position patient sitting on a chair (with space behind), ad-
equately expose neck. Inspect from front and sides for any obvious goitres or swell-
ings, scars, signs of hypo-/hyperthyroidism.

History and examination

2 Swallow test
Standing in front of the patient ask them to “sip water…hold in your mouth …and
swallow” to see if any midline swelling moves up on swallowing.

3 Tongue protrusion test

Ask patient to "stick out your tongue". Does the lump move up?

If evidence favours lump not arising

from thyroid, examine lump like any
other (p596)

4 Palpation
Stand behind the patient.
• Proptosis: (p211) whilst standing behind the patient ask them to tilt their head
back slightly; this will give you a better view to assess any proptosis than when
assessing the other aspects of eye pathology from front on, as in 8)
• The thyroid gland: ask the patient “any pain?” Place middle 3 fingers of either
hand along midline below chin and ‘walk down’ to thyroid. Assess any enlarge-
ment/ nodules
• Swallow test: repeat as before, now palpating; attempt to ‘get under’ the lump
• Lymph nodes: examine lymph nodes of head and neck (p60). Stand in front of
the patient
• Trachea: palpate for tracheal deviation from the midline.

5 Percussion
Percuss the sternum for dullness of retrosternal extension of a goitre.

6 Auscultation
Listen over the goitre for a bruit.

7 Hands
• Inspect: for thyroid acropachy (clubbing) and palmar erythema
• Temperature
• Pulse: rate and rhythm
• Fine tremor: ask patient to “hold hands out”, place sheet of paper over out-
stretched hands to help.

8 Eyes
• Exophthalmos: inspect for lid retraction and proptosis (p211)
• Lid lag: ask patient to “look down following finger” as you move your finger from
a point above the eye to below
• Eye movements: Ask patient to follow your finger, keeping their head still, as you
make an ‘H’ shape. Any double vision?

9 Completion
Ask patient to stand up from the chair to assess for proximal myopathy, look for
pretibial myxoedema, test ankle reflexes (ask patient to face away from you with
knee resting on chair). Thank patient and wash hands.
 1 Inspection 69
Introduction, consent, position patient sitting on a chair (with space behind), ad-
equately expose neck. Inspect from front and sides for any obvious goitres or swell-
ings, scars, signs of hypo-/hyperthyroidism.

History and examination

2 Swallow test
Standing in front of the patient ask them to “sip water…hold in your mouth …and
swallow” to see if any midline swelling moves up on swallowing.

3 Tongue protrusion test

Ask patient to "stick out your tongue". Does the lump move up?

If evidence favours lump not arising

from thyroid, examine lump like any
other (p596)

4 Palpation
Stand behind the patient.
• Proptosis: (p211) whilst standing behind the patient ask them to tilt their head
back slightly; this will give you a better view to assess any proptosis than when
assessing the other aspects of eye pathology from front on, as in 8)
• The thyroid gland: ask the patient “any pain?” Place middle 3 fingers of either
hand along midline below chin and ‘walk down’ to thyroid. Assess any enlarge-
ment/ nodules
• Swallow test: repeat as before, now palpating; attempt to ‘get under’ the lump
• Lymph nodes: examine lymph nodes of head and neck (p60). Stand in front of
the patient
• Trachea: palpate for tracheal deviation from the midline.

5 Percussion
Percuss the sternum for dullness of retrosternal extension of a goitre.

6 Auscultation
Listen over the goitre for a bruit.

7 Hands
• Inspect: for thyroid acropachy (clubbing) and palmar erythema
• Temperature
• Pulse: rate and rhythm
• Fine tremor: ask patient to “hold hands out”, place sheet of paper over out-
stretched hands to help.

8 Eyes
• Exophthalmos: inspect for lid retraction and proptosis (p211)
• Lid lag: ask patient to “look down following finger” as you move your finger from
a point above the eye to below
• Eye movements: Ask patient to follow your finger, keeping their head still, as you
make an ‘H’ shape. Any double vision?

9 Completion
Ask patient to stand up from the chair to assess for proximal myopathy, look for
pretibial myxoedema, test ankle reflexes (ask patient to face away from you with
knee resting on chair). Thank patient and wash hands.