What are the key components of a physical exam for thyroid assessment?

Key Components of a Physical Exam for Thyroid Assessment

A thorough thyroid physical examination should include inspection, palpation, and assessment of related structures to detect abnormalities that may indicate thyroid dysfunction or disease.

Inspection

• Observe the neck for visible enlargement, asymmetry, or obvious nodules
• Look for signs of hyperthyroidism or hypothyroidism (puffy face, coarse skin, slow movements)
• Assess for surgical scars from previous thyroid procedures

Palpation Technique

1. Position the patient properly:

   • Patient seated with neck in neutral position
   • Use neck flexion, side bending, and rotation to minimize structures between examiner's fingers and thyroid 1

2. Posterior approach:

   • Stand behind the patient
   • Place fingers on either side of the trachea below the cricoid cartilage
   • Have patient swallow sips of water to feel the thyroid move upward

3. Anterior approach:

   • Stand in front of the patient
   • Use both hands to palpate the thyroid gland

Specific Assessment Parameters

• Size: Assess for enlargement (goiter)
• Consistency: Note firmness, softness, or irregular texture
• Nodules: Document location, size, firmness, fixation 2
• Tenderness: Note any pain with palpation
• Mobility: Thyroid should move with swallowing

Additional Essential Components

• Lymph node examination: Assess for cervical lymphadenopathy
• Auscultation: Listen for bruits over thyroid (indicating hypervascularity)
• Cranial nerve assessment: Evaluate for potential compression effects 2
• Voice quality: Assess for hoarseness (possible recurrent laryngeal nerve involvement)
• Tremor assessment: Check for fine tremor of outstretched hands
• Reflex testing: Evaluate for brisk reflexes (hyperthyroidism) or delayed relaxation phase (hypothyroidism)

Related Structures to Examine

• Salivary glands: Palpate parotid and submandibular glands 2
• Skin and scalp: May reveal cutaneous manifestations of thyroid disease 2
• Eyes: Check for exophthalmos, lid lag, or periorbital edema
• Heart: Assess for tachycardia, atrial fibrillation, or bradycardia
• Extremities: Evaluate for pretibial myxedema or peripheral edema

Important Considerations

• Physical examination alone has limited accuracy in diagnosing thyroid dysfunction, with modest sensitivity and specificity 3
• Approximately 18.5% of patients without palpable thyroid abnormalities may have lesions detectable by ultrasound 4
• The combination of coarse skin, bradycardia, and delayed ankle reflex has the highest likelihood ratio for hypothyroidism but is still only modestly accurate 3

When to Consider Further Evaluation

• Abnormal findings on physical examination
• Symptoms suggestive of thyroid dysfunction despite normal examination
• High-risk individuals (family history, radiation exposure, etc.)
• Patients with nodules ≥1cm or suspicious characteristics 2

Remember that while physical examination is an essential first step in thyroid assessment, laboratory testing (TSH, free T4) and imaging studies (ultrasound) are often necessary for definitive diagnosis of thyroid disorders.