COLLEGE OF MEDICINE AND HEALTH SCIENCES

SCHOOL OF NURSING AND MIDWIFERY

DEPARTMENT OF ADULT HEALTH nursing
Advanced physical Examination of thyroid gland and lymph
nodes

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 Anatomy
• Site = thyroid gland is located In front of
lower Part of neck anterior to the larynx
• consists of 2 lobes
Right and the left lobes
• Normally Right lobe is slightly larger than left lobe
• Each lobe extends from middle of thyroid cartilage
to fourth or fifth tracheal ring.
• Shape = thyroid gland has the shape which is
like Butterfly
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 physiology
Thyroid gland is an Endocrine gland
• Thyroid secreting Hormones are belonging to the Amine
Group of Hormones, derived from the amino acid Tyrosine:
• Thyroxin (T4)
• Tri-iodo thyronine (T3)
• Thyroid secretions are under influence of TSH (thyroid
Stimulation Hormone) from pituitary gland

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 Steps of Examination
Before proceeding to the examination we should
have to take a proper history.
• Introduce your self
Explain the procedure to the pateint
• Gain consent
• confirm pateint detail
• washing hand
• collect instrument
• Position the patient – sitting on a chair

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 Nesesary Instruments
Stethoscope
Glass of water
Piece of paper
• Tendon hammer

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 Examination con.t
• The examination consists of:
Inspection,
Palpation,
Percussion
Auscultation

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 Examination con.t
• The examination consists of:
Inspection,
Palpation,
Percussion
Auscultation

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 Inspection
Anterior Approach

Lateral Approach

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 What we Inspect
• Behavior
• Hands
• Pulse
• Face
• Eyes
• Thyroid

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 Behavior
Does the patient appear hyperactive?
agitation anxiety (hyperthyroidism)
Does the patient appear hypoactive? depressed –
(hypothyroidism

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 There may be a link
between hypothyroidism and depression. It is more likely
that hypothyroidism causes symptoms of depression,
rather than depression leading to hypothyroidism. For
example, hypothyroidism can affect hormone production
and disrupt chemical signaling in the brain, leading
to depress

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When our thyroid gland is overactive, all processes pf our
body be come speed up. This acceleration can bring about:
nervousness. anxiety.

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 Hypo con,t
• hypothyroidism occurs when the gland is
underactive. This can present itself at any age, but
the risk increases as you get older, and it is most
commonly triggered by genetics. Women are
three times more likely than men to develop
hypothyroidism.
• “When you have an underactive thyroid,
your immune system is triggered to fight your
thyroid, causing inflammation, which causes your
thyroid to produce fewer thyroid hormones.”

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 Con.t
• . “The symptoms are typically vague and often
resemble those that occur in other disorders,
like iron deficiency. Therefore, it can be often
confused with other conditions that cause
fatigue.
• Common causes of hypothyroidism
include:
• an autoimmune disorder
genetics
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 hyperthyroidism symptoms and
treatment
 Hyperthyroidism is basically the opposite of
hypothyroidism.
It occurs when the thyroid is overactive, producing
too much thyroid hormone.
Common causes of hyperthyroidism include:
Graves' disease, a common autoimmune condition
that stimulates the thyroid hormones T4 and T3

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 Hands
• Inspect the patients hands for…
• Dry skin (hypothyroid)
• Increased sweating (hyperthyroid)
• Thyroid acropachy – phalangeal bone
overgrowth – Graves’ disease
• Palmar erythema – redness of the palms
hyperthyroidism

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 Hands con.t
Peripheral tremor
• 1. Ask the patient to place their arms straight out
in front of him
• 2. Place a piece of paper across the backs of their
hands
• 3. Observe for a tremor (the paper will vibrate)
• Presence of tremor indicates hyperthyroidism

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 PULSE

Assess the radial pulse for…

 Rate:
• Tachycardia (Hyperthyroidism)
• Bradycardia (hypothyroidism)
 Rhythm – irregular – thyrotoxicosis

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 Face
• Inspect the face for…
• Dry skin – hypothyroidism
• Sweating – hyperthyroidism
• Eyebrows– loss of the outer third
hypothyroidism (altered hair growth)

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 Eye
• Exophthalmos (Anterior displacement of the eye out
of the orbit)
• Note if the sclera is visible above the iris (lid
retraction) – seen in Graves’disease
• Inspect for any redness / inflammation of the
conjunctiva

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 Eye con,t
• Lid lag
• 1. Hold your finger high & ask the patient to
follow it with their eyes
• 2. Move your finger downwards
• 3. Observe the upper eyelid as the patient
follows your finger downwards
• lid lag occurs as a result of the anterior protrusion
of the eye from the orbit (exophthalmos) which is
associated with graves’ disease
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 Thyroid
• Inspect the midline of the neck (in the region of
the thyroid)
• Any skin changes / erythema?
• Any scars? – previous thyroidectomy

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 Thyroid cont
• Masses
• Note any swelling / masses in the area
1 assess size
shape
concistency
normaly thyroid gland should not be visible

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 Thyroid con.t
• If a mass is noted on inspection…
2 Ask patient to swallow some water:
• Observe the movement of the mass
If the mass is embedded in the thyroid gland it will
move with swallowing
• Thyroglossal cysts will also move with swallowing
• If the mass is Lymph node it will move very little
• There is no significant movement

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 Thyroid cont
• 3 Ask patient to protrude their tongue:
Normaly
• Thyroid gland masses and lymph nodes will not
move upward but
• Thyroglossal cysts will move upward noticeably
• And visible through the mouth

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 palpation
Anterior Approach

Posterior Approach

• Thyroid examination is best carried out from

behind, with patient’s neck slightly extended.
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 Palpation cont
• Stand behind the patient & ask them to
slightly flex their neck (to relax the
sternocleidomastoids).
• Place your hands either side of the neck.
• Ask if the patient has any pain in the neck
before palpating

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 Palpation cont
• When palpating the thyroid gland, assess the following:
• Size – does it feel enlarged? Or not
if it is enlarged it is g o i t e r
• Symmetry – is one lobe significantly larger than the other?
Normaly the right lobe is slitely larger than the left
• Consistency – does the thyroid smooth or nodular?
If we feel irregular mass it may be multinodular g o i t e r
• Masses – are there any distinct masses within the thyroid
gland’s

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 Palpation cont
• Procedure:
• 1. Place the 3 middle fingers of each hand along the
midline of the neck below the chin
• 2. Locate the upper edge of the thyroid cartilage
(“Adam’s apple”)
• 3. Move inferiorly until you reach the cricoid cartilage /
ring
• 4. The first 2 rings of the trachea are located below the
cricoid
• cartilage and the thyroid isthmus overlies this area
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 Palpation cont
• 5. Palpate the thyroid isthmus using the pads of your
fingers (index fingers) (not the tips)
• 6. Palpate each lateral lobe of the thyroid including
inferior border
• turn by moving your fingers down and slightly laterally
from the isthmus
• 7. Ask the patient to swallow some water, to feel for
symmetrical elevation
(asymmetrical elevation may suggest a unilateral thyroid mass)
• 8. Ask the patient to protrude their tongue once
more (if a mass is a thyroglossal cyst, it will rise during tongue
protrusion)

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 Palpatio con
• If a mass is noted…
• Assess – position / shape / tenderness and
mobility

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 Palpation con.t trachea
• Note any deviation of the trachea –if we get
devated trachea
• may be caused by a large thyroid mass
• Normally there is no any deviation on the
trachea

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 Trachea

Normally, trachea is midline; palpate for

any tracheal shift
Space should be symmetric on both
sides
Note any deviation from midline

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 percusion
• Percuss downwards from the sternal notch.
• Retrosternal dullness may indicate a large thyroid mass,
extending posterior to the manubrium.( broad upper
part of sternum)

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 Auscultation
• Auscultate each lobe of the thyroid for a
bruit
• A bruit would suggest that increased vascularity, which
occurs in Graves’disease
• bruit is soft palatal whooshing and blowing sound
heard by stetoscope

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 Anatomy and physiology of lymphatic
system
Lymphatic system is: an extensive vessel system,
is major part of immune system, detects/ eliminates
foreign substances from body
Vessels allow flow of clear, watery fluid from tissue
spaces into circulation
Nodes are small, oval clusters of lymphatic tissue that
filter lymph and engulf pathogens and preventing
potentially harmful substances from entering the
circulation greatest supply of lymphatic system is in
head and neck

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 Normal and abnormal findings on lymph node
Normally lymph nodes feel movable, discrete, soft,
and non-tender
size of lymph nodes is not more than 1cm
Abnormal nodes greater than 1 cm
If we get >1cm not for its
location, size, shape, (discrete or matted together),
mobility, and tenderness
If nodes enlarged or tender, check area they drain for
source of the problem; they often relate to
inflammation or neoplasm in head and neck

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 Special Tests
• Reflexes – e.g. Biceps – hyporeflexia is associated with
hypothyroidism
• Inspect for pre-tibial myxedema – associated with Graves’
disease
• Proximal myopathy:
• Ask patient to stand from a sitting position with arms
crossed
• An inability to do this suggests proximal muscle wasting
• Proximal myopathy is associated with hyperthyroidism

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 Con.t
• Thank patient
• Wash hands
• Summarize findings

Further assessments & investigations

• Thyroid function tests (TSH / T4)
• ECG – if irregular pulse noted
• Further imaging – USS
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