Thyroid nodule

Any individual mass palpable within the thyroid gland. Nodules are typically benign, may be hyperfunctioning, and may occur within a multinodular goitre, but always require assessment for possible malignancy. Diagnosis is usually clinical but assessment should always include serum hormone testing, and may require uptake scanning or ultrasound guided fine needle aspiration.

General examination

To diagnose thyroid nodule 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 shouId improve rapidly with treatment, though it may indicate malignancy.

Breast examination

An isolated neck lump may represent a lymph node or thyroid metastasis. Thorough examination is thus essential.

Cardiovascular system

Detailed cardiac assessment is necessary.

Tachycardia, atrial fibrillation, hypertension and congestive cardiac failure may complicate hyperthyroidism.

Eyes

Lid retraction and lid lag may be seen in any cause of thyrotoxicosis - 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.

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 hyperthyoidism, as is a general increase in resting movement or 'jumpiness' in the patient during examination.

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 of generalised nodularity or of distinct lumps or lymph nodes must be noted.

Ask the patient to swallow while palpating any nodules - thyroid nodules should rise and fall with swallowing, and move freely under the skin.

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 as high as they can. Facial flushing, engorgement of the neck veins, and inspiratory stridor all indicate superior vena cava obstruction.