Steps For Palpating The Thyroid Gland

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■ Ask the patient to flex the neck slightly forward to relax the sternomastoid muscles.

■ Place the fingers of both hands on the patient's neck so that your index fingers are just below the cricoid cartilage.

■ Ask the patient to sip and swallow water as before. Feel for the thyroid isthmus rising up under your finger pads. It is often but not always palpable.

■ Displace the trachea to the right with the fingers of the left hand; with the right-hand fingers, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed sternomastoid. Find the lateral margin. In similar fashion, examine the left lobe.

The lobes are somewhat harder to feel than the isthmus, so practice is needed. The anterior surface of a lateral lobe is approximately the size of the distal phalanx of the thumb and feels somewhat rubbery.

■ Note the size, shape, and consistency of the gland and identify any nodules or tenderness.

If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect a bruit, a sound similar to a cardiac murmur but of noncardiac origin.

Although physical characteristics of the thyroid gland, such as size, shape, and consistency, are diag-nostically important, they tell you little if anything about thyroid function. Assessment of thyroid function depends upon symptoms, signs elsewhere in the body, and laboratory tests. See Table 5-24, Thyroid Enlargement and Function (p. 208).

Soft in Graves' disease; firm in Hashimoto's thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis

A localized systolic or continuous bruit may be heard in hyperthyroidism.

The Carotid Arteries and Jugular Veins. You will probably defer a detailed examination of these vessels until the patient lies down for the cardiovascular examination. Jugular venous distention, however, may be visible in the sitting position and should not be overlooked. You should also be alert to unusually prominent arterial pulsations. See Chapter 7 for further discussion.

■ Special Techniques_

For Assessing Prominent Eyes. Inspect unusually prominent eyes from Exophthalmos is an abnormal above. Standing behind the seated patient, draw the upper lids gently upward, protrusion of the eye (see p. 177).

and then compare the positions of the eyes and note the relationship of the corneas to the lower lids. Further assessment can be made with an exophthal-

mometer, an instrument that measures the prominence of the eyes from the side. The upper limits of normal for eye prominence are increased in African


For Nasolacrimal Duct Obstruction. This test helps to identify the cause of excessive tearing. Ask the patient to look up. Press on the lower lid close to the medial canthus, just inside the rim of the bony orbit. You are thus compressing the lacrimal sac.

Look for fluid regurgitated out of the puncta into the eye. Avoid this test if the area is inflamed and tender.

Look for fluid regurgitated out of the puncta into the eye. Avoid this test if the area is inflamed and tender.

Inspect Puncta
Regurgitation of mucopurulent fluid from the puncta suggests an obstructed nasolacrimal duct.

For Inspection of the Upper Palpebral Conjunctiva. Adequate examination of the eye in search of a foreign body requires eversion of the upper eyelid. Follow these steps:

■ Instruct the patient to look down. Get the patient to relax the eyes— by reassurance and by gentle, assured, and deliberate movements. Raise the upper eyelid slightly so that the eyelashes protrude, and then grasp the upper eyelashes and pull them gently down and forward.

■ Place a small stick such as an applicator or a tongue blade at least 1 cm above the lid margin (and therefore at the upper border of the tarsal plate). Push down on the stick as you raise the edge of the lid, thus everting the eyelid or turning it "inside out." Do not press on the eyeball itself.

■ Secure the upper lashes against the eyebrow with your thumb and inspect the palpebral conjunctiva. After your inspection, grasp the upper eyelashes and pull them gently forward. Ask the patient to look up. The eyelid will return to its normal position.

Upper Palpebral Conjunctiva
This view allows you to see the upper palpebral conjunctiva and look for a foreign body that might be lodged there.

Swinging Flashlight Test. This test helps you to decide whether reduced vision is due to ocular disease or to optic nerve disease. For an adequate test, vision must not be entirely lost. In dim room light, note the size of the pupils. After asking the patient to gaze into the distance, swing the beam of a penlight back and forth from one pupil to the other, each time concentrating on the pupillary size and reaction in the eye that is lit. Normally, each illuminated eye looks or promptly becomes constricted. The opposite eye also constricts consensually.

When the optic nerve is damaged, as in the left eye below, the sensory (afferent) stimulus sent to the midbrain is reduced. The pupil, responding less vigorously, dilates from its prior constricted state. This response is an afferent pupillary defect (Marcus Gunn pupil). The opposite eye responds consensually.

When ocular disease, such as a cataract, impairs vision, the pupils respond normally.

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