How to Perform A Thyroid Exam - Clinical Skills - Dr Gill

[Music] [Music] hello and welcome back to the channel my name is dr james gill and you've joined us for another in-depth examination review looking at the clinical skills for how to do the thyroid examination so we're joined again by abby who's going to help us go through that thyroid status assessment so to start off we want to actually observe the patient before they come into the room we want to watch them walking down the corridor how are um you know they're moving do they appear agitated do they feel particularly slow does it look as if there's been any obvious changes to their weight are they clothed tighter than you might expect or may have seen before similarly we can also look at the patient's belt buckles does it look like they've lost weight and had to tighten all the way through are there any easy signs that might help us to think this is a hyper or hypothyroidism patient when the patient is sat down obviously we're going to greet them so could you please confirm your name and date of birth please at least what 7th of december 1996. thank you and at the same time we're going to make sure that we're gelling our hands so that we're all safe and secure obviously we would have washed our hands anyway before seeing each patient but i think the extra step is always worthwhile so to start off with the thyroid patient as i say we are going to observe them from the end of the bed and comment about their general status do they seem calm and anxious is there any sort of puffiness to the face that we might think about with a hypothyroidism and we're going to start off with the hand so if you could put your hands out in front please now there's a plethora of things that we need to look at in the hands so starting off with the nails we can't see any choline so spoon shaping of the nails we might associate with an iron deficiency anemia we can't see any clear issues with excess sweating or if there's any abnormal temperatures we can't see a very important sign something called thyroid acropatchy where we have swelling of the distal phalanxes the tufts there the bones which can be quite painful thankfully there's no evidence of that here we've got a normal capillary refill so easily less than two seconds but similarly we're not a very a hyperdynamic circulation which might suggest a hyperthyroidism if you could turn your hands over we're again going to have a look to see um if the signs of anemia from the palmer creases which can become pale in hypothyroidism on the converse we can have palmer erythema where the palms become bright red which can be seen in various conditions such as liver cirrhosis in pregnancy and also in hyperthyroidism a crucial thing that we need to do is get the patient to put their fingertips together with their nails touching so we can see if there's any signs of clubbing here we're looking for shamroth sign the presence of a window at the top of the nails showing there is no clubbing with a thyroid patient the presence of clubbing might strongly suggest a hyperthyroidism case because it is only seen in graves as opposed to hypothyroidism so if you continue to put your hands outstretched one of the things that we may see with a hypothyroidism case is a fine tremor now that may be something that we can see straight away but possibly not in which case we can put a bit of paper on the hands to see if that tremor becomes exaggerated now thankfully apart from a slight anxiety in front of the cameras there is no uh tremor here if there was we'd see a significant increase in the mobility of the paper there so i'm a bear a very small brain so i like to work in straight lines so having had a look at the hands i'm going to progress up the arm doing the blood pressure and then having a look at the patient's face so with that in mind if i'm going to stretch out both hands please and i'm going to check the pulse at both both sides using my index and middle finger so i'm checking for a radial radial delay from a cardiology perspective what's not thyroid i'm still getting extra information at this point i'm checking for the patient's pulse rate so we're going to count for 15 seconds and multiply the number by four we're looking for a pulse that is less than 100 beats per minute so not tachycardia and we're looking for a pulse that is faster than 60 beats per minute not a bradycardia so we'd see a bradycardia with hypothyroidism and a tachycardia with anxiety or hyperthyroidism i also want to know what the rhythm is and i've got a nice regular rhythm there one two one two there's no arrhythmias and there's certainly no atrial fibrillation which may be suggested from hyperthyroidism i'm going to continue up to have a look at the arm so if you just roll up your sleeve please and i'm going to take the pulse again at the brachial artery so if you just move your arms slightly for me there we go so that's caused the biceps to contract i can feel the bicep tendon and i'm just checking for that pulse medially the bicep tendon now i'm feeling here for the character of the pulse is it a thick bounding pulse or is a weak thready pulse so again differentiating hyperthyroidism versus hypothyroidism thankfully here with abby with no thyroid problems we have a normal pulse at this stage it would be useful to do a blood pressure and then we carry on to have a look at the face as we mentioned we may see a swelling of the face edema if we've got a hypothyroidism we might also notice a changes to the hair hair might become thin and brittle with hypothyroidism or become waxy with a hypothyroidism similarly we can assess the eyebrows where hypothyroidism we lose the outer one-third we're going to focus to the eyes at this point again i can't see any puffiness around the eyes so we're then going to have a look as if there's any signs of anemia so if you just pull your eyelids down for me okay and we've got excellent conjunctiva on both sides so no problems there we're going to double check that by having a look at the mouth so if you show your tongue please okay and again there's no signs of anemia okay so we're just going to open nice and wide for me say ah okay and there's no problems down there at the back of the throat and there's no signs of anemia there so that's perfect we're going to carry on with the eyes for a moment and we're going to have a look for something called lidlac so abby i'm going to place my finger here and i need you to keep your head still but just follow my finger with your eyes up and down and down and what i'm looking for here we're going to do this slowly now is as my finger goes up i'm looking at the fact that abby's eyes are looking at my finger and as i drop it quickly her pupils follow down but her lid remains covering the top of her iris the coloured part of her eye if we have hyperthyroidism then we can have a lid lag whereby as the hand moves down and the eyes follow it we see a white over the iris because the lid is literally lagging behind the movement of the eye and this will be seen in hyperthyroidism with that we also want to assess the movement of the eye so keeping your head still again if you could follow my finger please tell me if there's any double vision at all okay so i'm watching abby's eyes going to the full extent of their movement if there's going to be any double vision i'd expect to see it toward the peripheries because something like hyperthyroidism may result in inflammation behind the eye it may result in inflammation to the muscles so you may have a slight change in the position of the orbit the eyeball itself and we're binocular visioned creatures we expect our eyes to be placed forwards all the while if we lose that binocular vision they have come out of alignment that's when we get double vision now somebody may have severe hyperthyroidism and present with something called exothalamus or proptosis where the eyes are visibly coming forward so we'd expect a visual problem to be presented quite early there however in very subtle cases we may not be able to see that clinically but we may pick it up if they identify double vision now going back to the and proptosis i'm just having a look at abby's eyes from the side and everything appears normal but i need to step behind to also have a look from the back so if you could lean backwards slightly and i'm looking over abby's face looking at the position of her eyeball of the orbit itself and whether or not it's pushing forwards compared to where it would be normally thankfully that's not the case here as we're behind the patient at this point we're also going to assess the lymph nodes so i need to make sure the patient is where i'm going to put my hands on their neck and palpate around so i'm just going to put my hands on your neck you're going to and we're going to see if we can find any lumps and bumps back there so just going to check under your chin so taking submental and submandibular along the jawline checking parotid and tonsillar then pre and post auricular and then checking at the back for the occipital and then over your deep and superficial chains on the neck we can't find anything untoward that's good and thankfully there are no obvious issues at this point now whilst i'm behind at the patient we're also going to have a look at their thyroid so i'm going to again put my hands on the patient's neck and i'm trying to assess the location of their thyroid so estrogen is the isthmus of the thyroid or should be i can't find any lobes there so that's good so thyroid is largely impalable which is what we'd expect here so that's very reassuring but if we did find any abnormalities there we'd want to trace out what it was we're finding was there an irregularity was there a change to the surface texture could we feel a lump could we feel one side of the thyroid being enlarged there are lots of things that we may be able to identify so we need to have a little bit of a closer look at the thyroid so for this here i'm going to get you to lean backwards for me and lie on bed and if you could just lean backwards for me and if you move your hair forwards okay and now i'm going to put my hand on the patient's chest and precurse over the chest to see if there's any sign of a retrosternal thyroid a thyroid that has gone down um in the neck okay so initially i i just wanted a precursor over your chest so it's going to involve me putting a hand on your chest is that okay okay okay so we've got an excellent uh resonance sound there so we know there's no signs of a retro sternal goiter so we also need to have a look at how the thyroid moves with swallowing so we can do that initially with a pen torch so if you can open your mouth please and put your tongue out and thank you and as she put her tongue out we did see a small movement there at the neck we're going to confirm this now if you could take a sample of water please and hold it please and then swallow okay i'm gonna do the same again i'm going to come stand behind you and i put my hands on your neck if you take the water in your mouth please and then swallow please super that's all normal okay so we've got a normal motion there so that's really reassuring now because the whole uh blood supply of the body will actually pass through the thyroid within minutes um it's vitally important in a thyroid examination we listen over the thyroid to see if there's any thyroid brewers a turbulent whooshing sound of the blood going by so to do that we get the patient to move their hair back from the neck we're going to take our stethoscope and we're going to breathe with the patient so take a deep breath in for me and hold it that's fine and breathe normally okay we'll do the same again deep breath in hold it and breathe normally once again so there's no signs of any breweries there so we're going to continue with the rest of the examination we need to continue on by uh checking the patient's reflexes so if you could spin your legs around to sit on the other side of the bed so we're going to check on the upper limb we're going to check at the bicep and also uh down at the wrist okay so abby's nicely uh making sure that we can get to that region first so if you could just slightly flex your arm please okay that's great so i've found a bicep tendon and i'm going to strike directly over it okay so we've got a good reflex there we're going to do the same again on the opposite side making sure we're comparing one side to the other all the way through and striking directly down and we can see that contraction and then we're going to check down near the wrist so if you just relax for me perfect and same again excellent so we've got good reflexes there we now need to have a look at the knees so if we just uncross your legs please okay and just relax for me to a nice loose and flop and we're just going to check over the patellar tendon okay so we've got a good reflex there and then on the opposite side okay so we've got a slightly brisk reflex there though did mention a little bit of anxiety before we started today didn't we yeah so we know that abby's not got any signs of hyperthyroidism so we're probably not going to put that down to anything significant but we do need to check the reflexes on your ankles so if you could swing your legs back onto the bed for me okay so we're just going to have a look at the reflexes of your ankles just let me move your leg please stay nice loose and floppy and strike the ankle excellent and relax for me i'll do the same again nice loose and floppy brilliant we've got an excellent response then terrific reflexes there we need to check for any peripheral edema by pressing on the inside of the tibia and that should be enough to displace any fluid there which would indicate the presence of peripheral edema which would associate with hypothyroidism so we haven't found any abnormalities today apart from happy slightly brisk reflexes we're going to put that down to the cameras uh watching things today so to complete our examination we want to check an ecg to make sure there's no signs of arrhythmia that we hadn't picked up manually and we'd also to complete it want to have a look at any blood panels that have been done particularly a full blood count to again make sure there's absolutely no anemia and also the thyroid function test the tsh so that we know the status of the thyroid biochemically as well as clinically well i hope that's been a useful video for you all um please consider liking the video it's been a benefit because that tells youtube we're here and please put any comments down below and we'll see if we can help you out with any questions about the thyroid status thanks so much take care i'll see you in the next one cheerio [Music]