EXAMINATION OF THE THYROID
 Inspection
o ?goitre/?nodule ?scars, dilated veins
o Watch a glass of water being swallowed 
only a goitre or thyroglossal cyst will rise
during swallow
 Palpation
o From behind with pulps of fingers over gland,
with pt head slightly flexed
o Size, Shape ?nodule
o Consistency ?rubbery in Hashimoto
thyroiditis, stony in carcinoma
o Tenderness is feature of thyroiditis
o Mobility  carcinoma tethers gland
o ?Thrill
o Cervical lymph nodes
o Move to front and re palpate
o Note trachea location
 Percussion on the upper sides of manubriums
 Auscultation on each lobe for bruit
 Pemberton’s sign
Changes During Pregnancy and thyroid hormone
 Transient increase T4 as bHCG acts to stimulant
 Who should be screened? Family history, Past history,
T1DM
 
HYPERTHYROIDISM
History
 When diagnosed and how
 Family history
 Vague constitutional sx – Sweating, Heat intolerance, insomnia,
hyperactivity, diarrhoea
 Weight loss
 Blurred vision, dry eyes, pain behind eyes
 Palpitations
 Muscle weakness
Examination
 General inspection ? weight loss, anxiety, thyroid facies
 Hands – tremor (lay sheet of paper over pt fingers), onycholysis
(flaky nails), palmar erythema, warm and sweaty palms
 Pulse ?HR and ?AF ?collapsing due to high output
 Eyes ?exophthalmos, thyroid stare,
o lid retraction – ask patient to follow finger down. Upper
lid lags behind
o Chemosis – oedema of conjunctiva and sclera injection
o Conjunctivitis
o Corneal ulceration because lids can’t close
o Optic atrophy rare
o Ophthalmoplegia – early loss of inferior rectus
 Neck – see above
Arms ?proximal myopathy
 Chest ?Flow murmur, CCF
 Legs ?pretibial myxoedema
HYPERTHYROIDISM INVESTIGATIONS AND MANAGEMENT
Investigations
Normal or High TSH with Low TSH with high T3 and T4 Low TSH with normal T3 and T4
high T3 and T4  Radioiodine uptake scan  Subclinical hyperthyroidism
 TSH-secreting pit. - diffusely increased uptake → Grave’s disease  If TSH 0.1 to 0.45
Adenoma. - no uptake → thyroiditis or exogenous thyroid - observe every 6 months with repeat
- need pituitary MRI hormone TFTs
 Resistance to thyroid Note: High faecal T4 levels in exogenous - no treatment unless age > 60 or Hx of
hormone hyperthyroidism cardiac disease
- look for family - hot spot(s) → functioning adenoma  If TSH < 0.1
history of  TSH-rec Abs → Grave’s disease - observe monthly with repeat TFTs
hyperthyroidism  Anti-TPO Abs, anti-TG Abs → Hashimoto’s - investigate for causes (radioiodine
thyroiditis uptake scan)
- commence treatment, especially if age
> 60, low BMD, cardiac Hx
Treatment – Graves Disease If planning pregnancy
 Propranolol 10mg TDS for symptomatic relief  Radioactive iodine at least 6 months before planned
 Carbimazole 10mg BD (blocks iodination of tyrosine) pregnancy. Obvious is CONTRAINDICATED in pregnancy
 Repeat TFTs monthly - monitor treatment with T3 and T4 - followed by 100mcg thyroxine daily, checking TFTs in one
[TSH levels take months to normalise] month
- once T4 levels halved, halve the dose of carbimzole - radioactive precautions for a few days (separate cutlery,
 Continue the carbimazole for 18 months, then stop the double flush, don’t hold kids)
medication to see whether the patient was in remission.  PTU can be used in pregnancy (carbimazole cannot).
 Side Effects of Carbimazole / PTU
- Agranulocytosis (advise to look for sore throat, fever)
- hepatic damage / glomerulonephritis / vasculitis
- nausea
HYPOTHYROIDISM THYROID NODULE
Causes Causes
 Autoimmune (Hashimoto’s)  Malignancy
 Idiopathic Anaplastic Papillary Medullary
 Drugs (carbimazole, PTU, lithium, amiodarone) Lymphoma Follicular Metastatic
 Thyroiditis (Silent, postpartum, subacute)  Adenoma
 Iodine deficiency
 Hypopituitarism Ix – see flow chart on next page
 Iatrogenic (surgery, RAI)
 Infiltrative (haemochromatosis, sarcoid, amyloid) If nodule is < 1 cm? Repeat USS in 6 months.

Investigations Monitoring after malignant thyroid cancer resection?

 TFTs  Continue T4 as replacement, also to suppress TSH (which
- high TSH (primary hypothyroidism) drives cancer)
- low TSH (secondary or tertiary hypothyroidism)  Repeat radioiodine uptake scan 6 months later
- pituitary MRI and measure FSH/LH/ACTH/LGF- - if scan +’ve proceed to radioactive iodine ablation
1/Prolactin/GH - if negative, repeat yearly for a few years.
 Antibodies. anti-Thyroid peroxidase, anti-Thyroid  Also measure Thyroglobulin levels yearly
globulin - if positive, RAI, and repeat, is still positive, consider PET
scan.
Treatment
 Remove cause if iatrogenic
 Commence thyroxine
- age > 60 start 50mcg / day
- start 100mcg / day
 Measure TFTs in one month
- primary – use TSH normalising as a goal
- secondary – use T4 normalising as a goal