EXAMINATION OF THE THYROID GLAND

- Dr Manas Ranjan Sahu, VIMSAR

Patient particulars

Name
Age Gender Address Education
Occupation
Date of admission, Date of examination.

CHIEF COMPLAINTS
 Swelling
 Pain.
 Pressure symptoms
 Symptoms of primary thyrotoxicosis
 Symptoms of secondary thyrotoxicosis
 Symptoms of myxedema (hypothyroidism)

HISTORY OF PRESENT ILLNESS

SWELLING
 Onset, Duration, Progression
 Associated symptoms like pain, dysphagia.
 Any other palpable swelling

PAIN
 Onset, Duration, Progression
 Nature of pain
 Radiation.
 Aggravating factor & Reliving factors

PRESSURE SYMPTOMS
 Dyspnea
 Dysphagia Hoarseness of voice

Signs of Horner's syndrome.

-Ptosis
-Miosis
-Enophthalmos
-Anhydrosis
Toxic symptoms
1) CNS toxicity
-Preference to cold
-Intolerance to heat
-Weight loss
-Excessive sweating
-Excitability/Nervousness
-Irritability/Insomnia
-Tremors of hand
-Muscle weakness.

2) CVS toxicity.
-Palpitations
-Pedal edema
-Dyspnea on exertion.
-Chest pain.

3) Eye symptoms.
-Diplopia
-Difficulty in closing the eyes.

4) GI symptoms.
-Weight loss
-Diarrhea

Symptoms of hypothyroidism.
 Increase in weight in spite of poor appetite
 Cold intolerance.
 Loss of hair.
 Muscle fatigue/Lethargy
 Failing memory
 Menstrual irregularity.
 Regular drug intake.

PAST HISTORY
 H/o similar complaints in the past.
 H/o of diabetes, hypertension, asthma, malignancy, Tuberculosis in the past.
 H/o surgery and medical interventions.
 H/o Drug allergy or allergy to food.

Menstrual history
Age of attainment of menarche Regularity cycles, duration of cycle
How many days of flow
Usage of pads/tampons/cloths-how many /day
Associated dysmenorrhea, passage of clots.
Amenorrhea or menorrhagia.

Marital history and obstetric history.

Family history
H/o similar complaints in the family
h/o diabetes, hypertension, asthma, malignancy, Tuberculosis in the past.

Personal history
Vegetarian /non vegetarian
Appetite
Sleep
Bowel and bladder habits
Substance abuse
H/o allergy to any drug, food

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, cooperative, well oriented to Time place and person.

Built (Skeletal frame work and height)
Nourishment (muscle mass/BMI)
Facies
Mental state and intelligence
Skin

Vitals:
Pulse
Blood pressure
Respiration.
Temperature.

Pallor Icterus, Cyanosis, Clubbing, Edema, Lymphadenopathy

Head to toe examination.

LOCAL EXAMINATION

INSPECTION
1. Situation, Size, Surface
2. Surrounding area
3. Extension
4. Color
5. Edge
 6. Number
7. Pulsation
8. Dilated veins Impulse on coughing
9. Movement with deglutition
10. Movement with protrusion of tongue
11. Skin over the swelling-red, edematous, tense, venous prominence, black
punctum, scar, pigment, ulcer. Any pressure effect
12. Position of trachea
13. E/o retro sternal goiter

PALPATION
1. All the inspectory findings should be confirmed
2. Local rise of temperature
3. Tenderness
4. Size
5. Shape, Extent, Surface, Edge
6. Consistency
7. Mobility
8. Fluctuation, Fluid thrill, Translucency
9. Impulse on coughing
10. Pulsatility- expansile, transmitted.
11. Sign of moulding /indentation
12. To get below the swelling
13. Position of trachea.
14. Kocher's test
15. Common carotid artery pulsation (Berry's sign)

 State of regional lymph nodes

 Any pressure effect
 Any toxic manifestations.
Percussion.
Auscultation.
Measurement
Movement.
Any pressure effect.

Examination of the eye.

 Lid retraction
 Lid lag
 Exophthalmos
 Difficulty in convergence.
 Staring look and infrequent blinking of eyes.
Systemic examination.
Cardiovascular system
Respiratory system
Abdomen
Central nervous system
Locomotor system

Summary
Solitary/Multinodular/Diffuse Benign/Malignant
Toxic/Non Toxic
Pressure symptoms present/not.

Provisional diagnosis
Differential diagnosis
Investigation
Treatment -Medical, surgery.
Follow-up.
Prognosis

CHIEF COMPLAINTS
Midline neck swelling since 7 years

HISTORY OF PRESENT ILLNESS

o Patient was apparently well 7 years back when she first noticed a midline
neck swelling of 1cm x 1 cm while bathing. She was pregnant with her 2nd
child at the time of noticing the swelling.
o Swelling had an insidious onset, was gradually progressive, increasing in size
from initially 1cm x 1cm to around 10cm x 7cm over 7 years.
o There is no recent rapid increase in size of swelling.
o Swelling is not associated with pain, difficulty in breathing, swallowing, facial
puffiness, hoarseness.
o There are no symptoms suggestive of hyperthyroidism and hypothyroidism.
o No history of weight loss, fever, upper respiratory tract infection, significant
goiterogen intake, chronic drug intake for any psychiatric illness and cardiac
disease.
o No complaints of any other neck or body swelling.
o Paraneoplastic history?

Past history
No previous history of hospitalisation or any neck surgery
Not a known case of Hypertension, Diabetes Mellitus, Asthma, Tuberculosis

Personal History
Patient takes a mixed diet.
She has a history of intake of unpackaged salt since her childhood.
She has normal bladder and bowel habits.
She has normal sleep cycle.
No history of substance abuse.

Treatment History
Patient took homeopathic treatment for the swelling for 2 years which didn’t relieve
the symptoms

Family History
No family history of thyroid disorder and any other malignancy

Menstural History
Regular menstural cycles.
Frequency- 28-30 days
Each lasting for 3-5 days
Average blood loss- 1 pad/ day

Obstetric History
o Patient is P2L2.
o Patient noticed the swelling for the first time during her 2nd pregnancy.
o Swelling didn’t resolve after the swelling.
o ?? Child having features of congenital hypothyroidism?
o There were no similar complaints in previous pregnancy.

Summary
My patient, 29 yr old female has a history of gradually progressing midline neck
swelling since 7 years with onset during her 2nd pregnancy and size increasing from
initial 1x1cm to 10x7cm over 7 years with no rapid rise in swelling. Swelling is not
associated with pain. Patient has a history of intake of unpackaged salt since her
childhood. There is no history suggestive of hyper/hypothyroidism and no history
suggestive of pressure effects.

Differential Diagnosis
Chronic progressive swelling- x infection
No rapid increase- x malignancy
No hyper- grave toxic adenoma
No hypo- hashimoto
Thyroid- Colloid goitre, Lymphocytic Thyroiditis, Non toxic adenoma, Thyroglossal
cyst
Non thyroid- Enlarged Para tracheal lymph nodes.

Examination
General Physical Examination
The examination has been done in well lit room and after taking due consent.
Patient is sitting comfortably on bed and is awake, alert and conscious
Patient has an average built and BMI of 21.2

VITALS:
Pulse -76pulse per minute in right radial artery, regular rhythm, good volume. All
peripheral pulses palpable.
BP- 130/80mmhg in right brachial artery in sitting position
Respiratory rate-15/min regular Thoraco-abdominal
Temperature- 98.5F

Head to toe examination

 Hair normal
 No pallor, icterus, Cyanosis
 No signs of Grave’s ophthalmopathy
 No Tongue and hand tremor
 Skin normal on touch
 Clubbing- absent
 No lymphadenopathy
 No pretibial and pedal edema

Thyroid Examination
INSPECTION
o Neck of patient well exposed, neck slightly extended.
o Symmetrical Midline neck swelling of size approximately 12cm wide x 7cm
height.
o Upper border of the swelling lie approximately 5cm below the mentum and
lower border not visible. On deglutition inferior border is visible.
o Lateral border of the swelling extending till the posterior border of
sternocleidomastoid muscle with swelling extending 6cm from the midline on
either sides.
o Swelling moves with deglutition but doesn’t move on protrusion of tongue.
o No overlying skin erythema, scar, opening in skin present, no dilated veins
over upper chest.
o Pamberton sign absent.
PALPATION
o Findings of the inspection have been confirmed on palpation.
o No local rise of temperature, no tenderness present.
o Diffuse Thyroid swelling of size 16.5cm wide x 7cm height is present with
o Upper border of the swelling lie approximately 5cm below the mentum and
lower border not palpable. On deglutition inferior border is palpable.
o Lateral border of the swelling extending till the posterior border of
sternocleidomastoid muscle with swelling extending 6cm from the midline on
either sides.
o Isthmus is 6.5 cm in width lying just below the thyroid notch.
o Swelling has smooth surface, firm consistency, well defined margins, no fixity
to skin present
o No palpable thrill present at upper poles.
o Carotid pulsation is felt at normal location.
o Kocher’s test is negative.

PERCUSSION
Resonant percussion note over manubrium and upper chest.

AUSCULTATION
No audible bruit present over the swelling.
Systemic examination
No significant finding present.

Summary
My patient, 29 year old female has a history of gradually progressing midline neck
swelling since 7 years with onset during her 2nd pregnancy and with no rapid rise in
swelling. Swelling is not associated with pain. There are no features suggestive of
hyper/hypothyroidism and no features suggestive of pressure effects.
On examination, Diffuse Thyroid swelling of size 16.5cm wide x 7cm height is
present with
Upper border of the swelling lie approximately 5cm below the mentum and lower
border not palpable. On deglutition inferior border is palpable.
Lateral border of the swelling extending till the posterior border of
sternocleidomastoid muscle with swelling extending 6cm from the midline on either
sides.
Isthmus is 6.5 cm in width lying just below the thyroid notch.
Swelling has smooth surface, firm consistency, well defined margins.
Pamberton sign absent, resonant percussion over manubrium and upper chest

Provisional diagnosis
Patient has a smooth firm thyroid swelling probably of benign origin, with no signs
of hyper/hypothyroidism, no local symptoms, no lymphadenopathy.
Differential Diagnosis-
Simple/Colloid Goitre
Lymphocytic thyroiditis

1. What are the differential diagnosis?

2. How is the thyroid gland palpated?
3. What is Lahey’s method of palpation of thyroid gland?
4. What is Pizzilo’s method of palpation of thyroid gland?
5. What is Crile’s method of palpation?
6. What are the swellings that move with deglutition?
7. Why does thyroid swelling move with deglutition?
8. Name the conditions where thyroid swellings have restricted movement with
deglutition.
9. What is the cause of hoarseness of voice in thyroid swellings?
10. What are the possible pressure effects of thyroid swellings?
11. Which swelling moves with protrusion of tongue and why?
12. What is Trial’s sign?
13. How to check carotid artery pulsation?
14. What is Berry sign?
15. Name the words with Berry.
16. What is Pemberton sign?
17. What is Kocher’s test?
18. Name the words with Kocher.
19. List the investigations in this case.
20. How will you confirm your diagnosis?
21. If FNAC is inconclusive, what should be done?
22. What radioactive isotopes are used for radioactive thyroid scanning?
23. Hot nodule, Warm nodule and Cold nodule
24. Role of X-Ray neck in this case?
25. Role of USG neck in this case
26. What is FNAC?
27. What is FNNAC?
28. Why we must do laryngoscopy in thyroid case?
29. What is Retrosternal goitre?
30. D/ds of Thyroid swellings
31. What is Goiter
32. Indications of Surgery in goiter
33. What is the difference b/w Solitary nodule Vs Dominant nodule?
34. What are the indications of surgery in solitary thyroid nodule?
35. When will you suspect malignancy in a solitary thyroid nodule?
 36. What surgery do you consider and what are the other thyroid surgery
procedures?
37. Preoperative preparation.
38. What is ectopic thyroid?
39. What is lateral aberrant thyroid?
40. What is Scabard trachea?
41. Name some painful conditions of Thyroid.
42. What are the types of Thyroiditis?

SURGICAL ANATOMY
1. ANATOMY OF THYROID GLAND
2. True capsule Vs false capsule
3. Blood supply- arterial supply, Vanous drainage
4. Nerve relationship
5. What is Tubercle of Zukerkandl?
6. Anatomy of parathyroid gland

OPERATIVE SURGERY
1. Which incision is made in Thyroidectomy?
2. Steps of Thyroidectomy.*
3. First vessel ligated during thyroid surgery is ____?
4. Accidentally removed parathyroid during thyroid surgery is kept in___?
5. Parathyroid after surgery is kept in______ muscle?
6. Preoperative complications
7. Early & late postoperative complications of thyroid surgery.
8. During surgery how will you confirm the tissue is parathyroid gland?
9. Common sites of injury to RLN?