Thyroid Status OSCE Examination

Contents

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

Introduction

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.

General Inspection

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 sympathetic (adrenergic) drive. 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.

Hands and Arms

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 the nail bed, sometimes called Plummer’s nails) is associated with thyrotoxicosis. Look also for thyroid acropachy, a rare sign specific to Graves’ disease in which there is soft tissue swelling of the digits and clubbing-like changes, caused by periosteal new bone formation. It tends to occur alongside the other Graves’-specific features of thyroid eye disease and pretibial myxoedema.

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 increased adrenergic activity of thyrotoxicosis and is one of the more reliable peripheral signs.

Image - Finger clubbing, with loss of the normal nail-fold angle. Thyroid acropachy in Graves’ disease can look similar but is driven by periosteal new bone rather than true clubbing

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.

Face and Eyes

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)]

Neck Inspection

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]

Thyroid Palpation

Palpation of the thyroid is performed from behind the seated patient. Always warn the patient that you are going to feel the front of their neck before you begin, and check again that they have no pain.

Ask the patient to tilt their chin slightly downwards to relax the strap muscles of the neck, which makes the gland easier to feel. Place the three middle fingers of each hand gently over the neck, find the thyroid cartilage in the midline, and move downwards to the cricoid cartilage. The isthmus of the thyroid lies just below the cricoid, with a lobe on either side.

Assess the gland systematically for:

• Size – is it enlarged (a goitre)?
• Symmetry – is enlargement diffuse (suggesting Graves’ disease or Hashimoto’s thyroiditis) or confined to one area?
• Consistency – a smooth, soft gland suggests a simple or diffuse goitre, a multinodular texture suggests a multinodular goitre, and a single firm or hard nodule raises the possibility of malignancy.
• Tenderness – a painful, tender thyroid suggests inflammation, as in subacute (de Quervain’s) thyroiditis.
• Mobility – confirm again, by asking the patient to swallow during palpation, that any swelling moves upwards.

While your hands are on the neck, also palpate the cervical lymph nodes in a systematic fashion. Enlarged nodes alongside a thyroid mass raise concern for thyroid malignancy with regional spread.

Tracheal Position, Percussion and Auscultation

Assess the position of the trachea in the suprasternal notch to check that it remains central. A large goitre can push the trachea to one side (tracheal deviation) and, importantly, can also compress it, so ask about any difficulty breathing or swallowing. Do this gently as it can be uncomfortable.

Percuss downwards from the sternal notch across the upper sternum. A change to a dull note suggests retrosternal extension of the goitre into the thoracic inlet, which is clinically important because it can compress the trachea and the great veins.

If retrosternal extension is suspected, consider testing for Pemberton’s sign. Ask the patient to raise both arms above their head and hold them touching the sides of the face for around a minute. A positive sign is the development of facial congestion, plethora or cyanosis, distended neck veins and sometimes stridor, and indicates that the retrosternal goitre is obstructing the thoracic inlet and compressing the great veins (a form of superior vena cava obstruction). It is a useful demonstration that a goitre is causing significant compression rather than being purely cosmetic.

Auscultate over each lobe of the thyroid for a bruit, using the bell of the stethoscope and asking the patient to briefly hold their breath so that breath sounds do not mask it. A bruit indicates increased and turbulent blood flow through the gland and is classically heard in the hypervascular, overactive gland of Graves’ disease.

Reflexes and Proximal Myopathy

The deep tendon reflexes are a useful indicator of thyroid status because thyroid hormone affects the speed of muscle contraction and relaxation. Test a reflex such as the biceps or ankle jerk and assess particularly the relaxation phase.

• Brisk reflexes are seen in hyperthyroidism.
• Slow-relaxing reflexes (the muscle relaxes noticeably slowly after contracting) are a classic sign of hypothyroidism.

Assess for proximal myopathy, which can occur in both over- and underactive thyroid states but is a particular feature of thyrotoxicosis. Ask the patient to stand up from a sitting position with their arms folded across their chest. Difficulty in doing so indicates weakness of the proximal lower-limb muscles.

Legs and Skin

Inspect the shins for pretibial myxoedema, a sign that – despite its name – occurs in Graves’ disease rather than in hypothyroidism. It is caused by the deposition of glycosaminoglycans in the dermis of the lower legs and appears as raised, waxy, discoloured plaques or non-pitting thickening over the anterior shins. It is one of the three Graves’-specific signs, alongside thyroid eye disease and thyroid acropachy.

More generally, look at the overall skin and hair. Hypothyroidism causes dry, coarse skin and brittle, thinning hair, while thyrotoxicosis tends to cause warm, moist skin and fine, soft hair.

Image - Pretibial myxoedema over the shins and thyroid acropachy of the hands. Both are specific signs of Graves’ disease

Creative commons source by Herbert L. Fred, MD and Hendrik A. van Dijk [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

Completing the Examination

Thank the patient and ensure they are comfortable and re-dressed appropriately.

Wash your hands.

Summarise your findings, stating clearly whether the patient appears clinically hyperthyroid, hypothyroid or euthyroid, and noting any features specific to Graves’ disease.

To complete the examination, suggest that you would:

• Perform a full set of observations including heart rate, blood pressure and temperature.
• Request thyroid function tests (TSH, free T4 and free T3) to confirm the biochemical thyroid status.
• Request thyroid autoantibodies (such as TSH-receptor antibodies and anti-TPO antibodies) where an autoimmune cause such as Graves’ disease or Hashimoto’s thyroiditis is suspected.
• Arrange a 12-lead ECG if there is any irregularity of the pulse, to look for atrial fibrillation.
• Arrange an ultrasound of the neck (with fine-needle aspiration if indicated) to further characterise any goitre or thyroid nodule.
• Refer to ophthalmology if there are signs of significant thyroid eye disease.
• Check a urinary pregnancy test in women of childbearing age, as pregnancy alters thyroid physiology and influences which treatments (such as radioiodine) are safe.

Quiz

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