Thyroid status examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This thyroid status examination OSCE guide provides a clear step by step approach to examining thyroid status.
Confirm patient details – name / DOB
Explain the examination
Position the patient (sitting on a chair)
- Glass of water
- Tendon hammer
- Piece of paper
Does the patient appear hyperactive? – agitation / anxiety / fidgety (hyperthyroidism)
Inspect the patients hands for…
Dry skin (hypothyroid)
Increased sweating (hyperthyroid)
Thyroid acropachy – phalangeal bone overgrowth – Graves’ disease
Palmar erythema – reddening of the palms at the thenar / hypothenar eminences – hyperthyroidism
1. Ask the patient to place their arms straight out in front of them
2. Place a piece of paper across the backs of their hands
3. Observe for a tremor (the paper will quiver)
Peripheral tremor can be a sign of hyperthyroidism.
Assess the radial pulse for…
- Tachycardia (hyperthyroidism)
- Bradycardia (hypothyroidism)
Rhythm – irregular (atrial fibrillation) – thyrotoxicosis
Inspect the face for…
Dry skin – hypothyroidism
Sweating – hyperthyroidism
Eyebrows– loss of the outer third – hypothyroidism (rare).
Exophthalmos (anterior displacement of the eye out of the orbit)
- Inspect from the front, side and above
- Note if the sclera is visible above the iris (lid retraction) – seen in Graves’ disease
- Inspect for any redness / inflammation of the conjunctiva
Bilateral exophthalmos is associated with Graves’ disease, caused by abnormal connective tissue deposition in the orbit and extra-ocular muscles.
1. Ask the patient to keep their head still and follow your finger with their eyes
2. Move your finger through the various axes of eye movement (“H“ shape)
3. Observe for restriction of eye movements and ask the patient to report any double vision or pain
Eye movement can be restricted in Graves’ disease due to abnormal connective tissue deposition in the orbit and extra-ocular muscles.
1. Hold your finger high and ask the patient to follow it with their eyes, whilst keeping their head still.
2. Move your finger downwards
3. Observe the upper eyelids as the patient follows your finger downwards
If lid lag is present the upper eyelids will be observed lagging behind the eyes’ downward movement (the sclera will be visible above the iris). Lid lag occurs as a result of the anterior protrusion of the eye from the orbit (exophthalmos) which is associated with Graves’ disease.
Inspect the midline of the neck (in the region of the thyroid)
- Any skin changes – e.g. erythema
- Any scars? – previous thyroidectomy scars can easily be missed
Note any swellings / masses in the area – assess size and shape
The normal thyroid gland should not be visible.
If a mass is noted on inspection…
1. Ask the patient to swallow some water:
- Observe the movement of the mass
- Masses embedded in the thyroid gland will move with swallowing
- Thyroglossal cysts will also move with swallowing
- Lymph nodes will move very little
2. Ask patient to protrude their tongue:
- Thyroid gland masses / lymph nodes will not move
- Thyroglossal cysts will move upwards noticeably
Stand behind the patient and ask them to slightly flex their neck (to relax the sternocleidomastoids).
Place your hands either side of the neck.
Ask if the patient has any pain in the neck before palpating.
1. Place the three middle fingers of each hand along the midline of the neck below the chin
2. Locate the upper edge of the thyroid cartilage (“Adam’s apple”)
3. Move inferiorly until you reach the cricoid cartilage / ring
4. The first two rings of the trachea are located below the cricoid cartilage and the thyroid isthmus overlies this area
5. Palpate the thyroid isthmus using the pads of your fingers
6. Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the isthmus
7. Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass)
8. Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it will rise during tongue protrusion)
When palpating the thyroid gland, assess the following:
- Size – does it feel enlarged? – goitre
- Symmetry – is one lobe significantly larger than the other?
- Consistency – does the thyroid feel smooth or nodular? – e.g. multinodular goitre
- Masses – are there any distinct masses within the thyroid gland’s tissue?
- Palpable thrill – sometimes noted in thyrotoxicosis – due to increased vascularity
If a mass is noted…
Assess – position / shape / tenderness/ consistency / mobility
Palpate for local lymphadenopathy:
- Supraclavicular nodes
- Anterior cervical chain
- Posterior cervical chain
- Submental nodes
Local lymphadenopathy may suggest metastatic spread of a primary thyroid malignancy.
Note any deviation of the trachea – may be caused by a large thyroid mass
Percuss downwards from the sternal notch.
Retrosternal dullness may indicate a large thyroid mass, extending posterior to the manubrium.
Auscultate each lobe of the thyroid for a bruit.
A bruit would suggest increased vascularity, which occurs in Graves’ disease.
1. Reflexes – e.g. biceps reflex – hyporeflexia is associated with hypothyroidism
2. Inspect for pretibial myxoedema – associated with Graves’ disease
3. Proximal myopathy:
- Ask the patient to stand from a sitting position with arms crossed
- An inability to do this suggests proximal muscle wasting
- Proximal myopathy is associated with hyperthyroidism
To complete the examination
Suggest further assessments and investigations
- Thyroid function tests (TSH / T4)
- ECG – if irregular pulse noted
- Further imaging – ultrasound scan
Mr Peter Truran