IM12.4-7 | Thyroid Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

The thyroid clinical evaluation is a multi-component skill integrating structured history-taking, systematic physical examination, and clinical reasoning to generate a prioritised differential diagnosis.

History domains: weight change, cardiovascular (palpitations, dyspnoea), neuropsychiatric (anxiety vs depression), GI (diarrhoea vs constipation), thermoregulation (heat vs cold intolerance), menstrual, neck symptoms, red flags for malignancy (hard fixed nodule, hoarseness, lymphadenopathy, RAI history), drug history (amiodarone, lithium, checkpoint inhibitors), family/autoimmune history.

Key examination signs:
- Thyrotoxicosis: Tachycardia, warm moist tremulous hands, onycholysis, lid retraction (all thyrotoxicosis); exophthalmos + bruit + pretibial myxoedema (Graves only); hyperreflexia; diffuse or nodular goitre
- Hypothyroidism: Bradycardia, cold dry skin, periorbital puffiness, Hertoghe sign, slow-relaxing ('hung-up') ankle jerk, hoarseness, firm rubbery goitre (Hashimoto)

Thyroid palpation: Posterior bimanual approach; patient neck slightly flexed; assess size (WHO grade 0/1/2), consistency (soft/firm/hard/tender), surface (smooth/nodular), mobility (fixed = red flag), nodule characteristics; auscultate for bruit (Graves).

Differential priority: Diffuse smooth goitre + bruit + exophthalmos = Graves. Multiple nodules + older patient = TMNG. Painful tender goitre + post-viral = de Quervain thyroiditis. Firm rubbery goitre + hypothyroid = Hashimoto. Hard fixed nodule + lymphadenopathy = malignancy.

Red flags requiring urgent action: Hard fixed nodule with lymphadenopathy (malignancy); hoarseness (RLN involvement); myxoedema coma (hypothermia, bradycardia, confusion, hypoventilation); thyroid storm features (high fever, altered consciousness, AF, cardiac failure).

REFLECT

Think back to the patient from the opening hook — a young woman with palpitations, weight loss, heat intolerance, and protruding eyes. Before any investigation, the clinical examination had already told you: thyrotoxicosis (tachycardia, tremor, weight loss) AND specifically Graves disease (exophthalmos — not present in other causes of thyrotoxicosis). The blood test confirmed it; the examination predicted it. Now consider a more challenging scenario: an elderly man who presents primarily with new-onset atrial fibrillation and heart failure, with a small, barely palpable nodular goitre. Would you think to check thyroid function? Thyrotoxicosis — especially in older men — can present in a 'masked' form (apathetic hyperthyroidism) without the adrenergic features of tremor, anxiety, or heat intolerance. The only clues may be new AF, weight loss, or proximal weakness. Developing a reflex to check TSH in any new-onset AF or unexplained weight loss is the mark of a clinician who treats the whole patient, not just the presenting complaint. What other clinical presentations might you add to your personal checklist for 'when to think thyroid'?