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 make sure you state your grade, for example 3rd year medical student, junior doctor or consultant.

Confirm the patient’s details by checking 3 points of identification, usually full name, date of birth and NHS or hospital number.

Obtain consent for the examination. Explain that you will 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 (having too much thyroid hormone in the blood). Excess thyroid hormone raises metabolic activity and makes tissues more sensitive to adrenaline-type (adrenergic) signals. 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. Hoarseness can occur in hypothyroidism because of myxoedematous changes of the larynx (swelling of the voice box tissues from a jelly-like build-up). Rarely, it occurs because a thyroid mass presses on the recurrent laryngeal nerve (the nerve that supplies the muscles of the voice box). Hoarseness that does not get better, especially alongside a thyroid lump, can be a sign of thyroid cancer and needs further assessment.

Glance around the bedside for clues such as medications (e.g. carbimazole, an antithyroid drug; levothyroxine, thyroid hormone replacement; propranolol, a beta blocker) or a glass of water for the swallow test later.

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. Rarely, you may see thyroid acropachy, a sign of autoimmune thyroid disease that is strongly associated with Graves’ disease (an autoimmune cause of an overactive thyroid). It combines soft-tissue swelling of the digits, digital clubbing and periosteal new bone formation. Clubbing is rounding of the fingertips with loss of the angle at the nail bed. Periosteal new bone is new bone laid down under the periosteum (the membrane covering the bone). The bone changes are demonstrated on imaging, not by inspection alone. Acropachy usually accompanies thyroid eye disease (eye changes caused by Graves’ disease) and thyroid dermopathy (thickened, waxy skin changes). It 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. In thyrotoxicosis, tissues are more sensitive to adrenergic signals, which causes a fine tremor. Tremor is one of the features that should make you suspect an overactive thyroid.

Image - Schamroth’s window (the diamond-shaped gap seen between the nails when the nails of opposite fingers are placed back to back) 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 (no pattern at all to the beats). Thyrotoxicosis is an important and reversible cause of atrial fibrillation (a fast, irregular heart rhythm arising in the atria), so always check for this rhythm if thyrotoxicosis is suspected.

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 Graves’ disease can cause its own eye disease (thyroid eye disease), which can be present even when thyroid hormone levels are normal. Proptosis and restricted eye movement are the signs that point most strongly to Graves’ disease. Lid retraction and lid lag are common in thyroid eye disease but can also come from excess thyroid hormone, so they are less specific. In Graves’ disease, autoantibodies (antibodies that attack the body’s own tissues) stimulate inflammation and the deposition of glycosaminoglycans (large sugar-based molecules that attract water) in the orbital tissues (the tissues of the eye socket) and the extraocular muscles (the muscles that move the eye). This pushes the eye forwards and restricts 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 (drying and damage of the cornea, the clear front surface of the eye).

Look also for signs of active inflammation: a red, bloodshot conjunctiva (the clear membrane over the white of the eye) and chemosis (conjunctival swelling and oedema). These suggest the thyroid eye disease is currently active rather than inactive. This matters because active disease may respond to treatment that dampens the immune system (immunosuppression).

Look for lid retraction, where the upper eyelid is pulled up so that sclera (the white of the eye) is visible above the iris (the coloured part), giving a startled appearance (Dalrymple’s sign). Lid retraction has more than one cause. In thyrotoxicosis, overactive sympathetic nerves raise the tone of the superior tarsal (Müller’s) muscle, a small muscle in the upper eyelid that helps lift it. In thyroid eye disease, overaction of the lid-lifting muscles and, later, scarring of them also pull the lid up.

Assess eye movements by asking the patient to follow your finger through the cardinal directions of gaze (up, down, left and right, usually traced as an H shape), 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 rectus muscles (which move the eye down and inwards) are most commonly affected. Ask about any pain on eye movement, which can indicate active inflammation.

Test for lid lag (von Graefe’s sign). Ask the patient to keep their eyes on your finger while you move the finger slowly downwards from a raised position. In thyrotoxicosis the upper eyelid lags behind the eye as it descends. It is thought to arise in the same ways as lid retraction.

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 cartilage (the Adam’s apple, part of the larynx). Note any obvious goitre (diffuse or nodular enlargement of the gland), any single lump, and any scars. A thyroidectomy scar (thyroidectomy is surgical removal of the thyroid) is typically a transverse incision low in the neck. It 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 (a sheet of connective tissue in front of the trachea) and is therefore tethered to the larynx, so a thyroid swelling (and a thyroglossal cyst, a fluid-filled lump left over from the path the thyroid took in the embryo) 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 (the remnant of the duct along which the thyroid descended in the embryo). It will move upwards when the tongue is poked out, whereas a true thyroid swelling will not. A lump that rises on both swallowing and tongue protrusion is a thyroglossal cyst. A lump that rises on swallowing only is a thyroid swelling.

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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