Thyroid Status OSCE Examination

1. Introduction
2. General Inspection
3. Hands and Arms
4. Face and Eyes
5. Neck Inspection
6. Thyroid Palpation
7. Tracheal Position, Percussion and Auscultation
8. Reflexes and Proximal Myopathy
9. Legs and Skin
10. Completing the Examination
11. Quiz

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; Full name, Date of birth and NHS/Hospital number.

Obtain consent for the examination ensuring to explain what the examination will entail, mentioning that you will need to look at their hands, eyes and neck and feel the front of their neck from behind.

Position the patient sitting on a chair with enough space behind them so that you can examine the neck from behind. Ideally the head and neck should be well exposed, so ask the patient to remove any scarves or high-necked clothing.

Ask if the patient has any pain anywhere before you begin, particularly in the neck.

Begin from the end of the bed with a general inspection of the patient and their surroundings, as this often gives away the diagnosis before you touch the patient.

Assess the patient’s general demeanour. A patient who is anxious, restless or fidgety may be thyrotoxic, as excess thyroid hormone increases sensitivity to adrenergic signals as well as metabolic activity. By contrast, a patient who appears lethargic, slow or low in mood may be hypothyroid, as a reduced metabolic rate slows physical and cognitive activity.

Look at the patient’s build. Weight loss despite a good appetite suggests hyperthyroidism (increased metabolic rate), whereas weight gain suggests hypothyroidism.

Inspect the patient’s clothing and assess their apparent comfort in the room temperature. Hyperthyroid patients are often heat intolerant and may be dressed lightly or sweating, while hypothyroid patients are typically cold intolerant and may be wearing extra layers.

Note any obvious neck swelling (a goitre) or any hoarseness of the voice, which can occur in hypothyroidism due to myxoedematous changes of the larynx or, rarely, due to a thyroid mass compressing the recurrent laryngeal nerve.

Glance around the bedside for clues such as medications (e.g. carbimazole, levothyroxine, propranolol) or a glass of water that you may use later during palpation.

Ask the patient to hold their hands out in front of them and inspect them carefully, as the hands carry several useful thyroid signs.

Look at the skin of the palms. Palmar erythema (reddening of the palms) can be a feature of thyrotoxicosis due to the increased peripheral blood flow that accompanies a high metabolic rate. Feel the temperature and moisture of the hands: warm and sweaty palms suggest hyperthyroidism, whereas cool and dry skin is more in keeping with hypothyroidism.

Inspect the nails. Onycholysis, separation of the nail from its bed, can accompany thyrotoxicosis but is not specific to it. Look for thyroid acropachy, a rare manifestation of autoimmune thyroid disease strongly associated with Graves’ disease. It combines soft-tissue swelling of the digits, digital clubbing and periosteal new bone formation. The bone changes are demonstrated on imaging, not by inspection alone. Acropachy usually accompanies thyroid eye disease and thyroid dermopathy and can occur after treatment when thyroid function is normal or low.

Assess for a fine tremor by placing a sheet of paper across the backs of the patient’s outstretched hands and watching for it to oscillate. A fine tremor reflects the enhanced sensitivity to adrenergic signals of thyrotoxicosis and is one of the more reliable peripheral signs.

Image - Schamroth’s window is present in the upper example and absent in the lower example, illustrating a bedside sign of digital clubbing. Thyroid acropachy can include true clubbing together with digit swelling and periosteal new bone formation; this diagram does not show the bone changes or establish their cause.

SimpleMed original

Take the radial pulse and assess its rate and rhythm. A tachycardia (rate above 100 bpm) supports hyperthyroidism, while a bradycardia (rate below 60 bpm) supports hypothyroidism. Crucially, check whether the rhythm is irregularly irregular, as thyrotoxicosis is an important and reversible cause of atrial fibrillation that should always be excluded.

Inspect the face first. Dry, coarse skin, a puffy appearance and loss of the outer third of the eyebrows are associated with hypothyroidism. By contrast, the skin in thyrotoxicosis may appear flushed and sweaty.

The eyes are the most important part of this section because several eye signs are specific to Graves’ disease rather than to thyroid hormone levels in general. In Graves’ disease, autoantibodies stimulate inflammation and the deposition of glycosaminoglycans in the orbital tissues and extraocular muscles, pushing the eye forwards and restricting its movement.

Inspect the eyes from the front and from the side for exophthalmos (also called proptosis), in which the eyeballs protrude forwards out of the orbit. This is best appreciated by standing behind the seated patient and looking down over their forehead. Severe proptosis can prevent the eyelids closing fully, risking exposure keratopathy and corneal damage.

Look also for signs of active inflammation: a red, injected conjunctiva and chemosis (conjunctival swelling and oedema) suggest the thyroid eye disease is currently active rather than burnt out, which matters because active disease may respond to immunosuppression.

Look for lid retraction, where the upper eyelid is pulled up so that sclera is visible above the iris, giving a startled appearance (Dalrymple’s sign). This is caused by sympathetic overactivity raising the tone of the superior tarsal (Müller’s) muscle, which helps elevate the upper lid.

Assess eye movements by asking the patient to follow your finger through the cardinal directions of gaze, keeping their head still. Restriction of movement and diplopia (double vision) occur when the inflamed, swollen extraocular muscles can no longer move freely – the inferior and medial recti are most commonly affected. Ask about any pain on eye movement, which can indicate active inflammation.

Test for lid lag (von Graefe’s sign) by asking the patient to follow your finger as you move it slowly from a raised position downwards. In thyrotoxicosis the upper eyelid lags behind the eye as it descends, again because of sympathetic overactivity of the lid retractor.

Image - Proptosis and lid retraction in Graves’ disease. The eyeballs are pushed forwards and sclera is visible above the iris, both classic signs of thyroid eye disease

Creative commons source by Jonathan Trobe, M.D., University of Michigan Kellogg Eye Center [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)]

Move to inspect the front of the neck, looking specifically over the region of the thyroid gland, which sits below the thyroid (laryngeal) cartilage. Note any obvious goitre (diffuse or nodular enlargement of the gland), any single lump, and any scars – a thyroidectomy scar is typically a transverse incision low in the neck and tells you the patient may now be on thyroid hormone replacement.

Ask the patient to take a sip of water, hold it in their mouth, and then swallow while you watch the neck. The thyroid gland is enclosed within the pretracheal fascia and is therefore tethered to the larynx, so a thyroid swelling (and a thyroglossal cyst) will move upwards on swallowing. Most other neck lumps, such as lymph nodes, will not move.

Next ask the patient to protrude their tongue while you observe. A thyroglossal cyst is connected to the base of the tongue by the thyroglossal tract and will move upwards when the tongue is poked out, whereas a true thyroid swelling will not. These two dynamic tests together help you decide what a midline neck lump is likely to be.

Image - A large goitre. Enlargement of the thyroid gland is visible as a midline swelling in the lower neck that would move upwards on swallowing

Public Domain Source Martin Finborud [Public domain]

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