Thyroid Examination (OSCE)

What is thyroid hormone T3? 

 A hormone which, alongside T4, regulates the body’s cellular functioning, controlling its metabolism, heart rate and temperature 

 When T3 is not bound to a protein, it is called ‘circulating T3’

 High levels of circulating T3, raises the metabolism, causing weight loss and potentially, excessive sympathetic output (anxiety, tremor, tachycardia) ⬇

 Low levels of circulating T3, lowers the metabolism, causing weight gain, constipation, low mood, hyporeflexia and bad memory ⬆

Introduction 

1. Greet patient and introduce yourself 
2. Confirm patient details ✍
3. Briefly explain the examination in a patient friendly manner 
4. Get patient consent ✅
5. Wash hands ✋
6. Expose patient’s upper sternum and neck 
7. Check the patient is not in any pain 

Equipment 

 Tendon hammer 

 Stethoscope 

 Glass of water 

 Paper 

Inspect the patient for any clinically relevant signs: 

 Behaviour: hyperactivity and anxiety indicate hyperthyroidism, low mood indicates hypothyroidism 

 Weight: weight loss indicates hyperthyroidism, weight gain indicates hypothyroidism  

 Voice: hoarse sounding voice indicates thyroid enlargement causing larynx compression 

 Clothes: too cold for the temperature indicates hyperthyroidism, too warm for the temperature indicates hypothyroidism 

Identify any clinically relevant objects/equipment: 

 Prescriptions: indicate recent medications 💊

 Mobility aids: indicate proximal myopathy caused by hyperthyroidism ♿

Hands 

Inspect the patient’s hands: 

 Onycholysis: hyperthyroidism can cause the nail to detach from the nail bed (painless) 

 Dry skin: caused by hypothyroidism 

 Palmar erythema: hyperthyroidism can cause red palms  ✋

 Thyroid acropachy: periosteal phalangeal bone overgrowth due to Graves’ disease 

 Sweating: hyperthyroidism can cause patients to sweat excessively 

Assess for peripheral tremor:  

1. Ask patient to stretch their arms out in front of them, palms facing the floor ✋
2. Put a piece of paper on the back of their hands 
3. Identify the tremor by observing whether the paper shakes 

Radial Pulse 

Use your index and middle fingertips to palpate the radial pulse:

 Assess the rate and rhythm of the pulse 💓

 Calculate the heart rate 

 Healthy: 60-100 bpm 

 Bradycardia: <60 bpm 

 Tachycardia: >100 bpm 

 Irregular rhythm: atrial fibrillation 

Face 

Inspect the face: 

 Eyebrow loss: the outer third of eyebrows is occasionally missing in hypothyroid patients 

 Dry skin: indicates hypothyroidism 

 Sweating: indicates hyperthyroidism 

Eyes:  

 Assess for pathology indicative of Graves’ disease 

 Lid retraction: inspect from front, indicated by the sclera being visible between the corneal limbus and upper lid margin 👁

 Exophthalmos: inspect from front, side and above, indicated by the eye bulging anteriorly 👁

 Inflammation: the eye is more prone to dryness, conjunctivitis, conjunctival oedema or corneal ulceration, when lid retraction and exophthalmos are present 

 Movement: Graves’ disease can cause restriction (ophthalmoplegia) and pain when moving the eye, assessed by asking the patient to follow your finger 

 Lid lag: this is when there is a delay between the eyeball moving to look downwards, and the upper eyelid doing so, assess by asking the patient to follow your finger downwards ⬇

Thyroid 

 Inspect the midline of the neck to identify any scars/masses 

Inspecting a mass: 

 Ask patient to swallow some water as you assess how the mass moves 

 Lymph nodes: move very little ❌

 Thyroid gland masses/thyroglossal cysts: move upwards ⬆

 Invasive thyroid malignancy: no movement (attached to tissue) ❌

Ask patient to stick their tongue out: 

 Thyroid gland masses/lymph nodes: no movement ❌

 Thyroglossal cysts: move upwards ⬆

Palpation of the thyroid 

1. Ask patient to tilt chin downwards ⬇
2. Stand behind patient and place your 3 middle fingers of both hands, below the chin, on the midline of the patient’s neck 
3. Identify the upper edge of the patient’s ‘Adam’s apple’ (thyroid cartilage) 
4. Lower your fingers to the cricoid cartilage to find the overlying thyroid isthmus ⬇
5. Palpate the thyroid isthmus 
6. Move your fingers outwards on both sides to palpate the thyroid lobes 
7. Keep your fingers on the thyroid lobes as the patient swallows water, assessing the movement (they should elevate symmetrically, asymmetrical elevation indicates a possible unilateral thyroid mass) 
8. Assess for mass by asking patient to stick their tongue out, a thyroglossal cyst which rise  ⬆

Thyroid gland characteristics: 

 Symmetry: identify asymmetry 

 Size: identify enlargement ⬆

 Masses: identify palpable masses 

 Consistency: identify irregularities 

 Palpable thrill: caused by hyperthyroidism, causing increasing the thyroid gland to become more vascularised 

Thyroid mass identification: 

 Assess the shape, consistency, mobility and position:

 Thyroglossal cyst: congenital, due to thyroglossal duct persistence, rise when tongue is protruded 

 Diffuse goitre: thyroid gland enlarged due to thyroid tissue hyperplasia 

 Uninodular goitre: single thyroid nodule, active (toxic, causing hyperthyroidism) or inactive 

 Multinodular goitre: multiple thyroid nodules, active or inactive 

Palpation of lymph node: 

 Local lymphadenopathy can indicate primary thyroid malignancy metastatic spread 

1. Ask patient to tilt chin downwards ⬇
2. Standing behind patient, palpate neck 
3. Assess lymph node characteristics simultaneously by using the pads of the fingers on both hands to roll the lymph nodes over the tissue surrounding them 
4. Assess all areas, beginning in the submental: 

          Submental 

          Submandibular 

          Pre-auricular 

          Post-auricular 

          Superficial cervical 

          Deep cervical 

          Posterior cervical 

          Supraclavicular 

Trachea 

 Observe if the trachea is deviated, possibly due to a goitre 

Percuss the sternum 

 Assess for retrosternal dullness by percussing from the sternal notch, downwards ⬇

 Retrosternal dullness can indicate a large thyroid mass  

Auscultate the thyroid gland 

 Use the bell of the stethoscope to auscultate the lobes of the thyroid gland and identify the presence of a bruit which is indicative of increased vascularity (Graves’ disease)  

More tests 

Assess the biceps or knee jerk reflex: 

1. Place your thumb over the patient’s relaxed brachii tendon  
2. Tap thumb with tendon hammer 
3. Assess whether the bicep contracts and elbow flexes  💪

 Reflexes allow you to identify hyporeflexia indicative of hypothyroidism 💪

Pretibial myxoedema: 

 Diffuse mucinosis 

 Presents as a waxy, discoloured hardening of skin on the shin 

 Rare Graves’ disease complication 

Proximal myopathy: 

 Can indicate multinodular goitre or Graves’ disease 

 Wastage of proximal muscles 💪

 Causes difficulty standing up (ask patient to sit then stand up whilst crossing their arms) 

Completion

1. Tell the patient the examination is complete ✅
2. Thank patient
3. Wash hands ✋
4. Summarise what the examination has revealed

Summary 

1. Greet the patient and explain the procedure
2. Inspect the patient to identify anything clinically relevant
3. Inspect and assess the patient's hands
4. Palpate the radial pulse
5. Inspect the face and eyes
6. Inspect and palpate the thyroid and inspect and palpate any masses
7. Palpate the lymph node
8. Assess whether the trachea is deviated
9. Percuss the sternum
10. Auscultate the thyroid gland
11. Perform any necessary additional tests