GENERAL EXAMINATION In general examination one should look for (i) primary toxic manifestations in case of goiters affecting the young, (ii) secondary toxic manifestations in nodular goiter and (iii) metastasis in case of malignant thyroid diseases. (1) Primary toxic manifestations: One should look for five cardinal signs (Fig. 27.17): 1. Eye signs: There are four important changes that may occur in the eyes in thyrotoxicosis (Figs. 27.18A to C). Each one may be unilateral or bilateral: (1) Lid retraction: This sign is caused by over- activity of the involuntary (smooth muscle) part of the levator palpebrae superioris muscle. When the upper eyelid is higher than normal and the lower eyelid is in its normal position this condition is called lid retraction. 'Lid lag' is a different term. This means the upper eyelid cannot keep pace with the eyeball when it Fig. 27.17: The four cardind ig of primary toxic goiter are shown by numbers. 1. Exophthalmos: 2, thyrod swelling with or without thrill 1. uch ycardia and 4. tremor. looks down following an examiner's 27.16)Both lid retraction and lid lag are not finger moving downwards from above. exophthalmos. partⅱ ) Exophthalmos (Fig. 27.19A and B): B When eyeball is pushed forwards due to increase in fat or edema or cellular infiltration in the retro-orbital space the eyelids are retracted and sclera becomes visible below the lower edge of the iris Figs. 27.19A and B: (A) Progressive (malignant) exophthalmos which developed over a period of 3 months following radiolodine therapy for thyrotoxicosis. Extensive chemosis and periorbital edema obscures the degree of exophthalmos; (B) A typical ex-ophthalmic goiter. first followed by above the upper edge of the iris. Now the following tests or signs are: (a) Von Graefe's sign: The upper eyelid lags behind the eyeball as the patient is asked to look downwards. (b) Joffroy's sign: Absence of wrinkling on the forehead when the patient looks upwards with the face inclined downwards. (c) Stellwag's sign: This is staring look and infrequent blinking of eyes with widening of palpebral fissure. This is due to toxic contraction of striated fibres of levator palpebrae superioris. (d) Moebius' sign: This means inability or failure to converge the eyeballs. (e) Dalrymple's sign: This means the upper sclera is visible due to retraction of upper eyelid. (i) Ophthalmoplegia: There may be weakness of the ocular muscles due to edema and cellular infiltration of these muscles. Most often the superior and lateral rectus and inferior oblique muscles are affected. Paralysis of these muscles prevents the patient looking upwards and outwards. (iv) Chemosis: This is edema of the conjunctiva. The conjunctiva becomes edematous, thickened and crinkled. Chemosis is caused by obstruction of the venous and lymphatic drainage of the conjunctiva by the increased retro-orbital pressure. 2. Tachycardia or increased pulse rate without rise of temperature is constantly present in primary toxic goiter. Sleeping pulse rate is more confirmatory in thyrotoxicosis. Regularity of the pulse may be disturbed and a rapid irregular pulse should arouse suspicion of auricular fibrillation (Fig. 27.20). 3. Tremor of the hands (a fine tremor) (Figs. 27.21 to 27.23) is almost always present in a primary thyrotoxic case. Ask the patient to straight out the arms in front and spread the fingers. Fine tremor will be exhibited at the fingers. The patient is also asked to put out the tongue straight (Fig. 27.21B) and to keep it in this position for at least 1/2 a minute. Fibrillary twitching will be observed. In severe cases the tongue and fingers may tremble Moist skin particularly of the hands and feet are quite common in primary thyrotoxic cases. It should be a routine practice to feel the hands just after feeling the pulse at the wrist. The palms are hot and moist and the patients cannot tolerate hot weather, on the contrary tolerance to cold is increased. Thyroid bruit is also quite characteristic in Graves' disease (primary thyrotoxic goiter). This is due to increased vascularity of the gland (Fig. 27.15). But this sign is a relatively late sign and mostly heard on the lateral lobes near their superior poles. (ii) Secondary thyrotoxicosis may complicate multinodular goiter or adenoma of the thyroid. The cardiovascular system is mainly affected. Auricular fibrillation is quite common. The heart may be enlarged. Signs of cardiac failure such as edema of the ankles, orthopnea, dyspnea while walking up the stairs may be observed. Exophthalmos and tremor are usually absent. Patients in this group are generally elderly. of a thyrud ate will be hrough the text (iii) Search for metastasis: When the thyroid swelling appears to be stony hard, irregular and fixed losing its mobility even during deglutition a careful search should be made to know about the spread of the disease. Besides examining the cervical lymph nodes, one should also look for distant metastasis such as bony metastasis which is quite common in thyroid carcinoma particularly the follicular type. The skull, the spine, the ends of the long bones, the pelvis, etc., should be examined for metastasis. Lastly metastasis in the lungs, which is not uncommon, should also be excluded.