• eye symptoms: ‘grittiness’, excessive tearing, retro-orbital

pain, eyelid swelling or erythema, blurred vision or diplopia

(these symptoms of ophthalmopathy occur in the setting

of autoimmune thyroid disease).

History suggesting hypothyroidism

Ask about:

• fatigue, mental slowing, depression

• cold intolerance

• weight gain, constipation

• symptoms of carpal tunnel syndrome

• dry skin or hair.

A

B

C D

Fig. 10.3 Thyroid enlargement. A 99mTechnetium radionuclide scan demonstrating diffuse goitre due to Graves’ disease. B Diffuse goitre due to

Graves’ disease. C Solitary toxic nodule. D 99mTechnetium radionuclide scan confirming multinodular goitre. (A and D) Courtesy of Dr Dilip Patel.

10.2 Features suggestive of Graves’ hyperthyroidism

History

• Female sex

• Prior episode of hyperthyroidism requiring treatment

• Family history of thyroid or other autoimmune disease

• Ocular symptoms (‘grittiness’, redness, pain, periorbital swelling)

Physical examination

• Vitiligo

• Thyroid acropachy

• Diffuse thyroid enlargement (can be nodular)

• Thyroid bruit

• Pretibial myxoedema

• Signs of Graves’ ophthalmopathy (proptosis, redness, oedema)

The physical examination • 197

10

Many clinical features of hypothyroidism are produced by

myxoedema (non-pitting oedema caused by tissue infiltration

by mucopolysaccharides, chondroitin and hyaluronic acid; Figs

10.4 and 10.5). Other common findings in hypothyroidism include

goitre, cool, dry or coarse skin, bradycardia, delayed ankle reflexes

and a slowing of movement.

Examination sequence

• Observe the facial appearance, noting signs of dry or

coarse hair and periorbital puffiness (Fig. 10.5).

• Inspect the hands for vitiligo, thyroid acropachy,

onycholysis and palmar erythema.

• Assess the pulse (tachycardia, atrial fibrillation,

bradycardia) and blood pressure.

• Auscultate the heart for a midsystolic flow murmur

(hyperthyroidism).

• Inspect the limbs for coarse, dry skin and pretibial

myxoedema.

• Assess proximal muscle power and deep tendon (ankle)

reflexes (p. 139).

Thyroid gland

Examination sequence

• Inspect the neck from the front, noting any asymmetry or

scars. Inspect the thyroid from the side with the patient’s

neck slightly extended. Extending the neck will cause the

thyroid (and trachea) to rise by a few centimetres and may

make the gland more apparent. Give the patient a glass of

water and ask them to take a sip and then swallow. The

thyroid rises (with the trachea) on swallowing.

• Palpate the thyroid by placing your hands gently on the

front of the neck with your index fingers just touching,

while standing behind the patient (see Fig. 10.1B). The

patient’s neck should be slightly flexed to relax the

Hyperthyroidism Hypothyroidism

Periorbital

oedema

Husky voice

Goitre

Bradycardia

Carpal tunnel

syndrome

Menorrhagia

Constipation

General

General

 increased appetite

ophthalmoplegia

(in Graves’ disease)

Graves’ disease)

Oligomenorrhoea

(in Graves’ disease)

Fig. 10.4 Features of hyper- and hypothyroidism. Fig. 10.5 Typical facies in hypothyroidism.

The physical examination

General examination

Look for signs of weight loss or gain (calculate the body mass

index), and assess the patient’s behaviour for signs of agitation,

restlessness, apathy or slowed movements. Patients may have

abnormal speech (pressure of speech suggests hyperthyroidism,

while speech is often slow and deep in hypothyroidism).

Hoarseness is suggestive of vocal cord paralysis and should

raise suspicion of thyroid malignancy.

Features of hyperthyroidism and hypothyroidism on examination

are summarised in Fig. 10.4.

Features of thyrotoxicosis include warm, moist skin, proximal

muscle weakness (due to a catabolic energy state), tremor

and brisk deep tendon reflexes. Hyperthyroidism may also be

associated with tachycardia or atrial fibrillation, and a midsystolic

cardiac flow murmur due to increased cardiac output.

Thyroid acropachy is an extrathyroidal manifestation of

autoimmune thyroid disease. It is characterised by soft-tissue

swelling and periosteal hypertrophy of the distal phalanges, and

mimics finger clubbing (see Fig. 10.2C). It is often associated with

dermopathy and ophthalmopathy. Pretibial myxoedema is a raised,

discoloured (usually pink or brown), indurated appearance over

the anterior shins; despite its name, it is specifically associated

with Graves’ disease and not hypothyroidism (see Fig. 10.2D).

198 • The endocrine system

• Assess eye movements (see Fig. 8.11). Graves’

ophthalmopathy is characteristically associated with

restriction of upgaze.

Lid retraction (a staring appearance due to widening of the

palpebral fissure) and lid lag (see earlier) are common eye signs

associated with hyperthyroidism. Both are thought to be due

to contraction of the levator muscles as a result of sympathetic

hyperactivity. Periorbital puffiness (myxoedema) is sometimes

seen in hypothyroidism.

Graves’ ophthalmopathy occurs in around 20% of patients

and is caused by an inflammatory infiltration of the soft tissues

and extraocular muscles (see Fig. 10.2A,B). Features suggestive

of active inflammation include spontaneous or gaze-evoked

eye pain, and redness or swelling of the lids or conjunctiva.

Proptosis (protrusion of the globe with respect to the orbit) may

occur in both active and inactive Graves’ ophthalmopathy and

is often referred to as exophthalmos. Inflammation of the orbital

soft tissues may lead to other more severe features, including

corneal ulceration, diplopia, ophthalmoplegia and compressive

optic neuropathy (see Fig. 8.8D).

sternocleidomastoid muscles. Ask the patient to swallow

again and feel the gland as it moves upwards.

• Note the size, shape and consistency of any goitre and

feel for any thrill.

• Palpate for cervical lymphadenopathy (see Fig. 3.27).

• Percuss the manubrium to assess for dullness due to

retrosternal extension of goitre.

• Auscultate with your stethoscope for a thyroid bruit. A

thyroid bruit (sometimes associated with a palpable thrill)

indicates abnormally high blood flow and is most

commonly associated with Graves’ disease. It may be

confused with other sounds: bruits from the carotid artery

or those transmitted from the aorta are louder along the

line of the artery.

Early simple goitres are relatively symmetrical but may become

nodular with time. In Graves’ disease the surface of the thyroid is

usually smooth and diffuse; in uninodular or multinodular goitre

it is irregular (see Fig. 10.3). Diffuse tenderness is typical of

viral thyroiditis. Localised tenderness may follow bleeding into a

thyroid cyst. Fixation of the thyroid to surrounding structures (such

that it does not move on swallowing) and associated cervical

lymphadenopathy increase the likelihood of thyroid malignancy.

Further investigation of thyroid disorders is summarised in

Box 10.3.

Eyes