TO START |
W2I2P4E2 | Wash your hands Wear appropriate PPE Introduce yourself and check patient’s Identity Permission: ‘Would it be alright if I examined your neck?’ Privacy: Ensure curtains to the bay are closed Pain: “Are you in any pain at all?” Position: Patient sitting upright in a chair positioned such that you can stand behind them. Exposure: To the clavicles, with long hair tied back. Equipment: Have a glass of water to hand
|
INSPECTION |
Surroundings
Patient | Monitoring - ECG, pulse oximetry Treatments - O2, IV access, NBM sign, tracheostomy, airway adjuncts
General appearance: well/unwell Hyperthyroid: thin, hot, flushed, agitated, wearing inappropriately little clothing for the weather. Hypothroid: fat, cold, thinning hair, tired, wearing inappropriately excessive clothing for the weather.
|
NECK |
Inspect | Inspect front and sides of the patient. Ask them to extend their neck slightly (‘look up slightly’) - easier to see lumps and scars hidden in neck creases Skin: scars, skin changes (eg facial plethora- ?SVC obstruction) Soft tissue: lumps, distension of neck veins -?SVC obstruction
Ask the patient to take a sip of water and hold it in their mouth. Then ask them to swallow. Observe for movement of the lump on swallowing (mass linked to thyroid) Ask the patient to stick out their tongue: observe for upward movement of any midline lump with swallowing (thyroglossal cyst)
|
Palpate
| Explain to the patient that you will be moving behind them to palpate their neck. Take this opportunity to inspect the back of their neck. Feel for: Thyroid (remember, thyroid isthmus level overlies the 2nd to 4th tracheal rings; the thyroid is not normally palpable) Palpate one lateral lobe at a time. Use the fingertips of one hand to gently push on one lobe to make the contralateral side easier to feel. Feel for nodules/masses and thrills. Also palpate the isthmus. Ask the patient to swallow another sip of water while palpating both thyroid lobes - thyroid masses move upward on swallowing.
Anterior and posterior triangles: palpate with flat of hand to feel for masses Parotid glands: Parotitis, salivary stone, tumour Lymph nodes: Submental, submandibular, anterior cervical, supraclavicular, posterior cervical, pre-auricular, post-auricular and occipital. Trachea (from the front): May be deviated if compression is due to neck mass. Warn the patient it might be uncomfortable first. Carotid pulse (from the front): Feel one side at a time. Any pulsatile masses? (aneurysms, dissections)
|
Percuss | |
Auscultate | For a thyroid bruit (indicated increased vascularity) Any other large masses, especially if they are pulsatile.
|
CLOSURE |
Closure | Thank the patient, ensure they are comfortable and dressed. Remove PPE Wash hands and equipment Pemberton’s sign: to look for thoracic outlet obstruction (mediastinal mass). Ask the patient to lift both their arms above their head. After a few moments, look for facial engorgement, cyanosis, distended neck veins or inspiratory stridor. This is distressing so offer the test but don’t do it unless asked.
|
To complete | |
|
THYROID STATUS EXAM |
Hands and arms | Temperature: hot, clammy (hyper) or cool (hypo) Pulse: tachycardia or AF (hyper) Tremor: best seen by placing a piece of paper over a patient’s outstretched hands. Fine (hyper), fast (thyrotoxicosis) Thyroid acropachy (clubbing and digit swelling: Graves’) Blood pressure: secondary hypertension (hyper)
|
Face
Thyroid eye disease (usually hyper)
Legs
Reflexes |
Periorbital oedema Exophthalmos (Graves’ specific) Lid retraction Lig lag on downward gaze (ask the patient to follow your vertically moving finger and look for sclera between iris and lid) Diplopia/ophthalmoplegia (go through eye movements)
Proximal myopathy (ask the patient to stand up from the chair with their arms across their chest; usually hyper) Pretibial myoedema (infiltrative dermopathy - waxy peau d’orange + non-pitting oedema of the anterior calf; indicated Graves’)
Brisk (hyper) Slow-relaxing (hypo)
|