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.
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.
Inspect eyes for exophthalmos
Inspect eyes from the sides
Inspect eyes from above
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
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
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 –assesssize 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
Inspect neck whilst patient swallowing
Inspect neck whilst protruding tongue
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)
Palpate thyroid cartilage
Move below the cricoid cartilage
Palpate the thyroid isthmus
Palpate each thyroid lobe
Palpate each thyroid lobe
Palpate whilst patient swallows
Palpate whilst patient protrudes tongue
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:
Anterior cervical chain
Posterior cervical chain
Local lymphadenopathy may suggest metastatic spread of a primary thyroid malignancy.
Palpate local lymph nodes
Note any deviation of the trachea – may be caused by a large thyroid mass
Assess tracheal position
Percuss downwards from the sternal notch.
Retrosternal dullness may indicate a large thyroid mass, extending posterior to the manubrium.
Percuss downwards over sternum
Auscultate each lobe of the thyroid for a bruit.
A bruit would suggest increased vascularity, which occurs in Graves’ disease.
Auscultate each thyroid lobe
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