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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. Check out the thyroid status examination mark scheme here.

Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain the examination

Gain consent

Position the patient (sitting on a chair)

Gather equipment

  • Stethoscope
  • Glass of water
  • Tendon hammer
  • Piece of paper

Inspection

Behaviour

Does the patient appear hyperactive? – agitation / anxiety / fidgety (hyperthyroidism)

  • General inspection

Hands

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

 

Peripheral tremor

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.

  • Inspect hands

Pulse

Assess the radial pulse for…

Rate:

  • Tachycardia (hyperthyroidism)
  • Bradycardia (hypothyroidism)

 

Rhythm – irregular (atrial fibrillation) – thyrotoxicosis

  • Assess pulse

Face

Inspect the face for…

Dry skin – hypothyroidism

Sweating – hyperthyroidism

Eyebrowsloss of the outer third – hypothyroidism (rare)

  • Inspect face
.

Eyes

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.

  • Inspect eyes for exophthalmos

Eye movements

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.

  • Assess eye movement

Lid lag

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.

  • Assess for lid lag

Thyroid

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

 

Masses

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
  • Inspect the neck

Palpation

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.

Thyroid gland

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)

  • Palpate thyroid cartilage

 

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

Lymph nodes

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.

  • Palpate local lymph nodes

Trachea

Note any deviation of the trachea – may be caused by a large thyroid mass

  • Assess tracheal position

Percussion

Percuss downwards from the sternal notch.

Retrosternal dullness may indicate a large thyroid mass, extending posterior to the manubrium.

  • Percuss downwards over sternum

Auscultation

Auscultate each lobe of the thyroid for a bruit.

A bruit would suggest increased vascularity, which occurs in Graves’ disease.

  • Auscultate each thyroid lobe

Special tests

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
  • Assess for hyporeflexia

To complete the examination

Thank patient

Wash hands

Summarise findings

 

Suggest further assessments and investigations

  • Thyroid function tests (TSH / T4) 
  • ECG – if irregular pulse noted
  • Further imaging – ultrasound scan
CONTENT REVIEWED BY

Mr Peter TruranEndocrine surgeon

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