Thyroid checklist

Graves’ ophthalmopathy

WIPPER and the intro

• Introduce yourself and shake hands
• Washing of hands and appropriate hand hygiene
• Asking for permission
• Ensuring the room’s privacy
• Ensuring the environmental warmth and good lighting conditions
• Asking for appropriate exposure (The neck and the upper chest)
• Asking the patient to be in the appropriate position (Sitting)
• Relocating to the right side of the patient
• Asking for a chaperon
• “I have all of my equipment’s”

General look of the patient

• Consciousness, alertness and orientation of the patient to time, place and person (After asking the 3 questions)
• Comment on the patient’s position and comfort
• Patient is not in distress, tachypnea or in pain, not obese nor thin
• Comment that the patient is showing normal facial expression, no apathy or agitation
• Ask the patient to say his full name
• Comment on the patient’s normal clothing for the weather
• Comment on normal speech with no hoarseness, no slow or pressured speech

Vital signs

• Mention that you want to check the pulse as tachycardia and atrial fibrillation occur with hyperthyroidism and bradycardia with hypothyroidism
• Mention that you will have to check the blood pressure for diastolic/systolic HTN
• Mention that you will have to check the BMI for weight gain/loss
• you might be asked to mention the rest of the vital signs

Hands

Inspect for; palm and dorsum

• No palmar erythema
• No thenar/hypothenar muscle wasting
• No vitiligo
• Normal hair distribution
• No dry and course skin

Nail changes;

• No finger clubbing
• No onycholysis
• No thyroid acropachy
• No brittle nails
• Do the usuals for palpation, check and comment on hand’s temperature, dryness/sweatiness

Tests;

• Ask the patient to extend his arms (يمد ايديه)
• Comment on no fine tremor
• Do the carpal tunnel test! (You can find it here in the mss checklist)

Face

• No dry or coarse hair, no hair loss
• No hair loss of last third of eyebrows (Hypothyroidism)
• No periorbital puffiness or myxedema
• No lid retraction
• Ask the patient to look at your finger without moving his head, test for lid lag (vertically move your finger)
• No lid lag
• No exophthalmos
• No proptosis
• No Conjunctival redness (Chemosis)
• Test for Ophthalmoplegia (H shape)!
• Comment on no diplopia or nystagmus

Thyroid

Inspection

• Ask the patient to hyperextend his neck, look at his thyroid
• No scars, swellings, skin lesions
• No asymmetry
• No visible dilated veins
• Ask the patient to swallow
• Mention that thyroid moves with swallowing
• Ask the patient to protrude his tongue
• Mention that thyroid doesn’t move (No thyroglossal cyst)
• Ask the patient to raise his arms, notice any facial congestions (Pemberton’s sign)
• Comment negative Pemberton’s sign

Palpation

• As always, do the usuals before palpation
• Stand behind the patient, ask him to slightly look down (Neck flexion)
• Palpate the thyroid
• Comment on symmetrical thyroid lobes
• Comment on no tenderness (Make sure to hold eye contact to notice any tenderness)
• Comment on no nodules or masses
• Comment on no enlargement
• Feel for thrills, comment on no thrills
• Mention palpating cervical lymph nodes! (should be skipped)
• Ask the patient to swallow, comment on thyroid moves while swallowing
• Ask the patient to protrude his tongue, comment on no movement

Tracheal tests

• Using 3 fingers, check for tracheal deviation (comment that it’s centralized)
• Ask the patient to take a deep inspiration, to check for tracheal tug
• Comment on no tracheal tug
• Measure the crico-sternal distance (Normally; 3 to 4 fingers)

Percussion

• Percuss over the clavicle’s head, note if there’s dullness

dullness = retrosternal goiter

• Comment on no dullness, normal resonance
• Percuss over the manubrium too, and comment no dullness, normal resonance

Auscultation

• Auscultate for thyroid bruit
• Mention no thyroid bruit
• Auscultate for murmurs
• Mention** no midsystolic murmur**

Finishing off your station!

I want to check/examine for;

• Proximal myopathy (Testing for it would be by asking the patient to stand up with his hands on his chest
• Test for deep tendon reflexes (in hypothyroidism = delayed relaxation, in hyperthyroidism = hyperreflexia)
• Pretibial myxedema of grave’s
• Ankle swelling of heart failure
• Lower limb skin if its dry and coarse

THE END