Thyroid nodule physical examination

Physical examination should focus on the thyroid gland and the lateral and central neck and should assess for supraclavicular and submandibular adenopathy. The most important finding in physical examination that need a more attention include assessing the nodule’s size and consistency, localized tenderness in the nodular area, lymphadenopathy, and physical exams coordinated with hypo- or hyperthyroidism.

Physical examination of patients with thyroid nodule is usually remarkable for:^[1][2][3][4]

• Tachycardia
  • A rapid pulse rate may suggest hyperthyroidism
• Hypertension
  • May occur in the context of multiple endocrine neoplasia type II (MEN II)
• Tachypnea may occur in the case of shortness of breath secondary to tumor enlargement effect

• Thyroid nodule
  • Solitary or dominant in a multinodular goiter
  • Characteristics of the nodule, including:
    • Size
    • Consistency (e.g., soft, firm, woody, or hard)
      • Nodules that are firm or immobile are more likely to harbor cancer than those that are soft or mobile
      • Large, firm cervical nodes ipsilateral to the thyroid nodule should suggest the possibility of local metastases from thyroid cancer
      • Firm to hard, irregular, fixed, non-tender nodule is more likely to be a thyroid malignant neoplasm
      • A smooth, soft, easily mobile nodule suggests a benign lesion, as does the presence of tenderness
      • Some benign nodules can be very hard because of calcifications
      • Multinodularity, especially if the nodules all have the same consistency, is consistent with a benign multinodular goiter. A nodule or mass that is dominant in size or has a different consistency than other nodules within the gland should be evaluated for malignancy more precisely
      • A midline nodule over the hyoid bone that moves up with protrusion of the tongue is likely to be a thyroglossal duct cyst.
    • Involvement with adjacent structures
• Cervical lymph nodes, including:
  • Submental and submandibular nodes
  • Upper jugular nodes
  • Midjugular nodes
  • Lower jugular nodes
  • Posterior triangle and supraclavicular nodes
  • Pretracheal, prelaryngeal, and paratracheal nodes
• Deviation of the trachea, which suggests a mass
• Hyperthyroidism
  • Secondary to TSH secreting adenomas
  • Palpitations
  • Insomnia
  • Anxiety
  • Weight loss
  • Heat intolerance
  • Diarrhea

Differentiated thyroid carcinoma (particularly papillary carcinoma) involves cervical lymph nodes in 20–50% of patients in most series using standard histopathological techniques, and may be present even when the primary tumor is small and intrathyroidal.^[5]

The frequency of micrometastases may approach 90%.^[6]

• Dyspnea
• Coughing
  • May become continous
  • Dysphagia
  • Hoarseness

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