• Patient conscious, cooperative and oriented to time, place and person.
• Examination performed in a well-lit room with adequate exposure.
• Verbal consent taken.
• Patient examined in sitting position.
General Physical Examination
Vitals
• Pulse: __ /min
• Blood Pressure:___mmHg
• Respiratory Rate:___ /min
• Temperature:___°F
• BMI: ____kg/m²
General Examination
• Pallor: Present / Absent
• Icterus: Present / Absent
• Cyanosis: Present / Absent
• Clubbing: Present / Absent
• Generalized Lymphadenopathy: Present / Absent
• Pedal Edema: Present / Absent
Features of Thyroid Dysfunction
- Hyperthyroidism
• Tremors: Present / Absent
• Warm palms: Present / Absent
• Sweating: Present / Absent
• Tachycardia: Present / Absent
• Exophthalmos: Present / Absent
• Lid lag: Present / Absent
• Hyperactivity/Irritability: Present / Absent
- Hypothyroidism
• Increased sensitivity to cold: Present / Absent
• Dry coarse skin: Present / Absent
• Bradycardia: Present / Absent
• Puffiness of face: Present / Absent
LOCAL EXAMINATION OF THYROID SWELLING
Inspection
Site and Extent
• Visible thyroid swelling: Present / Absent
• Size: ____ × ____cm
• Region involved: Right lobe, Left lobe, Isthmus, Both lobes, Diffuse enlargement
Lower Border
• Visible / Not visible
Skin Over Swelling
• Normal, Stretched, Shiny, Scarred, Pigmented, Ulcerated, Erythematous
Movement Tests
• Moves with deglutition: Yes / No
• Moves with protrusion of tongue: Yes / No
Neck Examination
• Visible cervical lymph nodes: Present / Absent
• Visible dilated veins: Present / Absent
• Visible pulsations: Present / Absent
• Scar: Present / Absent
• Sinus: Present / Absent
Other Positive Inspection Findings: ________
• Inspection findings confirmed by palpation.
Swelling Characteristics
• Solitary , Multinodular enlargement, Diffuse enlargement
• Site: Right lobe, Left lobe, Isthmus, Both lobes
• Size: ___ ×___ cm
• Surface: Smooth, Nodular, Irregular
• Margins: Well-defined, Ill-defined
• Consistency: Soft, Firm, Hard, Cystic
• Tenderness: Present / Absent
• Local rise in Temperature
Movement
• Moves with deglutition: Yes / No
• Moves with protrusion of tongue: Yes / No
Lower Border
• Palpable/Not palpable
Skin Over Swelling: Free/Fixed
Mobility: Mobile, Fixed to underlying structures
Trachea: Central, Deviated to Right / Left
Opposite Lobe: Normal, Enlarged
Thrill: Present/ Absent
Cervical Lymph Nodes
• Palpable / Not palpable
• If palpable:
- Site: ______________
- Number: ___
- Consistency: Soft / Firm / Hard
- Tenderness: Present / Absent
- Mobility: Mobile / Fixed
- Matting: Present / Absent
Retrosternal Extension
• Pemberton’s Sign: Positive/Negative
- Interpretation: Retrosternal extension Present / Absent
Percussion
• Manubrium Sterni: Resonant/ Dull
Auscultation
• Thyroid Bruit: Present/Absent
SYSTEMIC EXAMINATION
Cardiovascular System
• S1 and S2 normal.
• Murmur: Present / Absent.
• Tachycardia/Bradycardia: Present / Absent.
Respiratory System
• Bilateral air entry equal.
• Added sounds: Present / Absent.
Abdomen
• Soft and non-tender.
• Organomegaly: Present / Absent.
Nervous System
Signs of Hyperthyroidism
• Fine tremors: Present / Absent
• Hyperreflexia: Present / Absent
Signs of Hypothyroidism
• Delayed relaxation of ankle jerk: Present / Absent
• Hyporeflexia: Present / Absent
Clinical Diagnosis
Solitary Thyroid Nodule (STN)
Multinodular Goitre (MNG)
Diffuse Goitre
Toxic Goitre
Thyroid Malignancy
Other: ______________
Lobe Involved
Right lobe
Left lobe
Isthmus
Bilateral lobes
Cervical Lymphadenopathy
Present / Absent
Thyroid Functional Status
Euthyroid
Hyperthyroid
Hypothyroid
Thyroid Swelling Examination Summary
The patient is conscious and oriented to time, place and person. He/She is examined in a well-lit room, adequately exposed, in sitting position, after taking verbal consent.
General physical examination revealed pulse _/min, blood pressure _ mmHg, respiratory rate _/min, temperature ___°C and BMI _. Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema are present or absent accordingly. Signs of thyroid dysfunction such as tremors, cold or heat intolerance, warm palms, sweating, exophthalmos, lid lag, tachycardia, dry skin or bradycardia are present or absent accordingly.
On local examination of the neck, a solitary swelling of size __ × __ cm is present in the anterior aspect of neck, occupying the ______ region (right lobe/left lobe/isthmus/both lobes). The lower border of the swelling is visible/not visible. The overlying skin is ______. The swelling moves with deglutition and does/does not move with protrusion of tongue.
Other positive inspection findings included ______. No scar, sinus, dilated veins, ulceration, redness, pigmentation or visible pulsations are noted. No visible cervical lymph node enlargement is present.
My inspection findings are confirmed by palpation. A solitary/diffuse thyroid swelling of size __ × __ cm is present involving the ______. It has ______ surface, ______ margins, ______ consistency, is tender/non-tender, with no local rise in temperature. The swelling moves with deglutition and does/does not move with protrusion of tongue. The lower border is palpable/not palpable. Skin over the swelling is free/fixed. The swelling is mobile/fixed with respect to underlying structures. Trachea is central/deviated to the ______ side. Thrill is present/absent and tenderness is present/absent.
The opposite lobe is normal/enlarged. Cervical lymph nodes are palpable/not palpable. Retrosternal extension is present/absent as evidenced by Pemberton's sign being positive/negative.
Percussion over the manubrium sterni is resonant/dull.
On auscultation, a thyroid bruit is present/absent.
On systemic examination, CVS revealed normal S1 and S2 with no murmurs. Respiratory system showed bilateral air entry with no added sounds. Abdomen is non-tender with no organomegaly. Examination of the nervous system revealed normal findings/signs suggestive of thyroid dysfunction accordingly.
Clinical Summary
In summary, this is a case of solitary thyroid nodule / multinodular goitre / diffuse goitre involving the __________ lobe of thyroid with/without cervical lymphadenopathy and with/without features of hypo/hyperthyroidism.
