EXAMINATION OF SOLITARY THYROID NODULE

INSTRUCTION: EXAMINE THYROID GLAND/ NECK OF THIS LADY. TO PATIENT: HELLO MRS. SMITH. MY NAME IS DR. NAZISH GHAZANFAR. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY. MAY I PLEASE EXAMINE YOUR NECK? THANK YOU. LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS. COULD YOU PLEASE SIT ON THIS CHAIR AWAY FROM THE WALL WITH THE BUTTONS OF YOUR SHIRT UNDONE (EXPOSE UPTO CLAVICLE). ARE YOU CONFORTABLE MADAM. DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG? I AM JUST GOING TO HAVE A LOOK FIRST OF ALL. ACT: KNEEL; COME CLOSE TO LUMP, HANDS ON SIDE. LOOK AT LUMP FROM FRONT AND ITS SIDES. TO EXAMINER: THERE IS ON INSPECTION IN THIS LADY A SMALL LUMP IN THE ANTERIOR TRIANGLE OF NECK WHICH IS NODULAR ANDIS PRESENT ON RIGHT/LEFT SIDE OF MIDLINE. THERE IS NO EVIDENCE OF REDNESS, SCAR, VISIBLE NECK VEINS OR DISCHARGE IN THE OVERLYING SKIN AND THE SURROUNDING SKIN APPEARS TO BE NORMAL. ACT: GIVE PATIENT A GLASS OF WATER. TO PATIENT: COULD YOU PLEASE TAKE A SIP OF WATER AND HOLD IT IN YOUR MOUTH UNTIL I ASK YOU TO SWALLOW. ACT: STEP BACK, KNEEL (BE ON LEVEL OF LUMP) AND LOOK AT NECK OF PATIENT. TO PATIENT: COULD YOU PLEASE LOOK UP SLIGHTLY AND NOW SWALLOW PLEASE.

TO EXAMINER: THE LUMP MOVES UPWARDS ON SWALLOWING. IN CASE OF SMALL MIDLINE LUMP: TO PATIENT: COULD YOU PLEASE OPEN YOUR MOUTH. NOW PRESS YOUR INDEX FINGER AGAINST LOWER BORDER OF JAW TO KEEP JAW STILL. KEEPING YOUR JAW STILL NOW STICK OUT YOUR TONGUE. ACT: LOOK AT LUMP IN NECK. TO EXAMINER: THE LUMP DOES NOT MOVE UPWARDS ON STICKING OUT THE TONGUE. NOTE: THIS IS DONE TO EXCLUDE THYROGLOSSAL CYST. THYROGLOSSAL CYST MOVES UPWARDS ON STICKING OUT TONGUE BECAUSE TH THYROGLOSSAL DUCT EXTENDS DOWNWARDS FROM FORAMEN CAECUM OF TONGUE TO ISTHMUS OF THYROID GLAND. NOTE: THYROID GLAND IS INVESTED BY PRE TRACHEAL FASCIA AND IS ATTACHED FIRMLY TO CRICOID CARTILAGE AND SUPERIOR TRACHEAL RINGS BY THE SUSPENSORY LIGAMENT OF BERRY. THIS CAUSES IT TO MOVE UPWARDS ON SWALLOWING. OTHER SWELLINGS WHICH MOVE UPWARDS ON SWALLOWING ARE:
1. 2. 3. 4.

THYROID GLAND THYROGLOSSAL CYST SUBHYOID BURSITIS PRE LARYNGEAL OR PRE TRACHEAL LYMPH NODES FIXED TO LARYNX OR TRACHEA.

TO PATIENT: I WOULD NOW LIKE TO PALPATE THE LUMP. DOES IT HURT AT ALL? I WILL BE VERY GENTLE.JUST HOLD THIS GLASS OF WATER AND TAKE A SIP WHEN I ASK YOU TO. ACT: KNEEL IN FRONT OF PATIENT, CHECK TEMPERATURE WITH BACK OF HAND AND COMPARE IT WITH SURROUNDING SKIN. NOW CHECK FOR TENDERNESS. LOOK AT PATIENTS FACE AND ASK IF IT IS TENDER AT ALL. NEXT PINCH OVERLYING SKIN AND TELL PATIENT THAT YOU ARE JUST GOING TO PINCH THE OVERLYING SKIN. KEEP PATIENT INFORMED AT ALL TIMES.

NOW MOVE TO BEHIND PATIENT. ASK PATIENT TO BEND/ FLEX NECK SLIGHTLY AND PLACE THUMBS OF BOTH HANDS BEHIND NECK AND FINGERS OF BOTH HANDS ON FRONT OF LUMP. AND PALPATE THYROID GLAND/ LUMP. TO EXAMINER: I AM NOW PALPATING THYROID GLAND. THE OVERLYING SKIN IS NOT WARM. IT IS NON TENDER WITH A SMOOTH SURFACE. IT IS FIRM IN CONSISTENCY. TO PATIENT: NOW SWALLOW PLEASE. ACT: DETERMINE IF LUMP MOVES UPWARDS ON SWALLOWING AND ALSO KEEP ONE FINGER OF EACH HAND JUST ABOVE SUPRASTERNAL NOTCH TO FEEL LOWER BORDER OF THYROID TO EXCLUDE RETROSTERNAL EXTENSION. TO EXAMINER: THE OVERLYING SKIN MOVES EASILY OVER IT AND THE LUMP MOVES UPWARDS ON SWALLOWING WITH THE THYROID GLAND. IT IS NOT TETHERED TO THE OVERLYING SKIN. THERE IS NO EVIDENCE OF RETROSTERNAL EXTENSION. AND NOW I WILL FEEL THE CAROTID ARTERY, ONE SIDE AT A TIME.