00:01
So next stuff, we're going to
talk about the thyroid exam.
00:04
And not only we're going to
look at the thyroid itself,
but we're also going to
look for some of those
subtle manifestations of
hyper and hypothyroidism.
00:12
But first off,
let's reorient ourselves
to the anatomy of the
thyroid gland itself.
00:17
Oftentimes, people get mixed up
about the location of the thyroid
because they get hung up
on the thyroid cartilage.
00:22
So let's take a look at
the thyroid cartilage.
00:24
Shawn, if you can just tilt
your head up a little bit.
00:26
His "Adam's apple" is this prominent
cartilaginous shape right here.
00:32
At the very top of it is
this thyroid cartilage notch.
00:36
And then the ridge of it there
is the thyroid cartilage itself.
00:39
And while it's called
the thyroid cartilage,
it turns out the thyroid gland is really
not on top of the thyroid cartilage.
00:46
Instead,
I want you to walk down that ridge
until you feel a little gap.
00:50
And that's the gap between
the thyroid cartilage
and then much smaller cricoid
cartilage just inferior to that.
00:57
Typically, it's about a
centimeter or a half a centimeter
distal to the cricoid cartilage
is where you'll actually
find your thyroid gland.
01:06
Starting with the isthmus,
which is the section of thyroid
gland between the two lobes.
01:11
And then lateral to
that is of course,
where you'll find the
two lobes of the thyroid.
01:15
For some patients,
the isthmus and the thyroid
gland itself is buried
50% of it or even more of it
deep to the sternal notch.
01:24
And so it can become very
difficult to palpate.
01:26
Having a patient lift
their head up can sometimes
make the thyroid gland
a bit more prominent.
01:32
That being said,
it also stretches the skin
and sometimes can obscure the
bulge of the thyroid as well.
01:38
In his case, I can clearly
feel his cricoid notch here,
and therefore,
his isthmus is around here
and the thyroid
gland itself is here.
01:49
When palpating
the thyroid gland,
there's several specific
things you're looking for.
01:53
You're trying to see if there's
nodularity in the thyroid or asymmetry,
you're trying to see if there's
firmness in the thyroid,
which may be indicative
particularly with a firm thyroid
it may suggest Hashimoto's
with lymphocytic replacement,
and fibrous replacement
of the gland itself.
02:09
or a more soft full thyroid may
be indicative of something like
Graves' disease.
02:16
To further make sure that what you're
palpating if you do feel a nodule,
you can have the patient take
a sip of water and swallow
because since the thyroid
gland is attached to the
cartilaginous
structures in the neck.
02:29
When he swallows,
they shouldn't be lifted up,
they should come up
with his swallow.
02:34
As opposed to something
that's in the skin,
like a thyroglossal
cyst, for example,
it's going to stay where it is,
or move very minimally up and down.
02:41
So let's have him
take a sip of water.
02:47
Thank you.
02:49
I'm going to get my hands on his
neck hold that bolus of water.
02:54
Great.
02:55
And so I could still
feel his thyroid gland,
I could feel this tissue move up
and down underneath my fingertips.
03:01
You'll note by the way that I
tend to not examine patients
like this from behind.
03:06
And this is based on the
idea of trauma informed
physical exam where you really don't
want to stand behind somebody and
be in the position as if
you're strangling them.
03:15
Some folks have a
lot of trauma history
that may come up and
subsequent is history taking.
03:19
It's generally just something
to be avoided if you can help it
to stand behind somebody and have
them in a chokehold position.
03:24
So I stand from the side
like this and can achieve the
same thing with my fingers
without having to
worry about that.
03:32
Okay, so let's move on
to start looking for
some of the other
features of the thyroid.
03:37
You can actually auscultate
the thyroid gland.
03:39
And folks who have Graves' disease may
have evidence of a thyroid brewery,
which is this increased blood flow
due to a very hyperactive thyroid.
03:46
So that's very simply
done on either side.
03:52
And rather than the simple carotid
pulsation, which is very regular,
you're listening for the sound
of a rush of turbulent blood.
04:01
In this case,
it's essentially a flow murmur
or brewery through
the thyroid gland.
04:10
In addition,
whenever you're examining the thyroid
if you're concerned about
malignancy, for example,
you're going to want to perform a
lymph node exam in the same area
and the lymph node
exam in the neck
is going to be covered
in a subsequent lecture.