Expansion
Inspect, swallow, protrude tongue, palpate from behind, then assess function
Expansion
Inspection
- Neck swelling, scars, distended veins
- Ask the patient to swallow water: a thyroid mass moves up
- Ask the patient to protrude the tongue: a thyroglossal cyst moves, a thyroid mass does not
Palpation from behind
- Size, symmetry, consistency, nodules, tenderness
- Repeat while swallowing
- Lymph nodes and tracheal position
- Percuss for retrosternal extension; auscultate for a bruit (Graves disease)
Assess thyroid status
- Hyperthyroid: warm sweaty palms, fine tremor, tachycardia or atrial fibrillation, brisk reflexes, weight loss, lid lag
- Hypothyroid: bradycardia, dry skin, slow-relaxing reflexes, coarse hair, periorbital oedema
Eye signs of Graves disease are due to the orbitopathy, not the thyrotoxicosis, so they can occur in any thyroid state: exophthalmos, proptosis, chemosis, ophthalmoplegia and loss of colour vision. Lid lag and lid retraction by contrast are sympathetic effects of thyrotoxicosis from any cause.
Pemberton sign: raising the arms above the head causes facial plethora and distress in retrosternal goitre with thoracic inlet obstruction.