Multinodular goitre

Nodular thyroid swelling which may be associated with hyperthyroidism, and is not auto-immune in origin. The diagnosis is usually made clinically, though an ultrasound scan and thyroid function testing are often performed as part of the assessment.

General examination

To diagnose multinodular goitre a detailed and full general examination is essential in the initial assessment of all patients.

Body habitus, weight and BMI

Weight loss is common with thyrotoxicosis and should improve rapidly with treatment, though also occurs with malignancy.

Cardiovascular system

Detailed cardiac assessment is necessary.

Tachycardia, atrial fibrillation and other arrhythmias may occur in thyrotoxicosis.

Hypertension is also commonly seen with thyrotoxicosis.

Congestive cardiac failure may complicate both hyperthyroidism and hypothyroidism due to cardiomyopathy, or rate related failure.

Eyes

Lid retraction and lid lag may be seen in any cause of thyrotoxicosis. Lid retraction may be obvious at rest with the whites of the eyes visible above the iris. Ask the patient to watch your horizontal finger as you very slowly lower it about 30cm away from their eyes. Delay in the upper eye lid following downward gaze will reveal the whites of the eye above the iris in the presence of lid lag.

However, any asymmetry suggests Graves' disease not multinodular disease as the cause of thyroid dysfunction. More obvious Graves' ophthalmopathy is indicated by swelling around the eyes, redness of the whites of the eyes (conjunctival injection) or protrusion of one or both eyes visible from the side or above the head (proptosis or exophthalmos). Ask the patient to close their eyes and ensure there is no cornea visible indicating full lid closure. Test external ocular movements. Diplopia in any direction, and any loss of movement or frank ophthalmoplegia are usually due to muscle tethering. Acuity should also be tested. Drop in acuity in Graves' disease may indicate increased orbital pressure on the optic nerve which requires urgent assessment for decompression.

Hands and tremor

Examine the palms - hot, red and sweaty hands occur in hyperthyroidism.

Ask the patient to hold out their hands in front of them. A resting tremor is usually obvious in hyperthyroidism, but may be highlighted by placing a sheet of paper over the hands to demonstrate it shaking.

Reflexes

Brisk reflexes are seen in hyperthyroidism, as is a general increase in resting movement. Look for 'jumpiness' in the patient during examination.

Musculature

Proximal myopathy may occur with alterations in thyroid function. Ask the patient to slowly rise from a squatting position with a straight back and without using their arms or levering their upper body to help.

Muscle wasting may also occur in glucocorticoid deficiency.

Thyroid gland, neck and nodes

First inspect the neck from the front and ask the patient to swallow. Diffuse thyroid swelling, nodules, cysts and multinodular goitres may all be obvious as anterior neck masses that move on swallowing. Ask the patient to protrude the tongue – this should have no effect on a thyroid swelling.

Examine the neck thoroughly. This is usually performed from behind the seated patient and in a systematic fashion. The texture of the gland, tenderness, and the presence or absence nodularity or of distinct lumps or lymph nodes must be noted. Ask the patient to swallow while palpating any nodules.

Examine the patient for lymphadenopathy. Papillary cancer frequently has local lymphadenopathy at presentation. Distant lymph nodes are more likely to occur with follicular, anaplastic or other malignancies.

Pemberton's sign

Ask the patient to hold both arms above the head and hold them above their head as high as possible. Facial flushing, engorgement of the neck veins, and inspiratory stridor all indicate a positive test with superior vena cava obstruction.