Introduce yourself, confirm the patient's name and date of birth. Briefly explain the purpose of the procedure and degree of exposure required (you should be able to percuss the superior 1/3 of the sternum). Obtain consent and a chaperone and proceed to wash hands. Ask the examiner if they can chaperone you for the examination.
Hyper- or hypo-thyroid?
For ease of understanding throughout this page, all red and blue symptoms/signs will correspond to hyperthyroidism and hypothyroidism respectively.
General inspection
Ask the patient if they are in any pain and are comfortable.
Commence the examination by observing the patient from the end of the bed. Focus upon the patient’s body habitus and for any gross evidence of hyper/hypothyroidism:
Weight loss/gain.
Agitation or restlessness/apathy or lethargy.
Inappropriate clothing for the climate due to heat/cold intolerance.
Stereotypical facies/expression.
Excitable/depressive mood.
Inspect around the bed for any paraphernalia, including thyroid medications or walking aids, perhaps suggestive of proximal myopathy.
Ask if there has been any change in voice. Hoarseness is indicative of thyroid enlargement and may be a precursor sign before an overt goitre is visible
As the thyroid sits just inferior to the larynx, an impinging nodule may manifest with voice changes, and, amongst other causes of thyroid enlargement, can be a subtle sign of thyroid cancer.
Hands
Inspection of the hands should be done in an intentional and noticeable way. Inspect the nails for thyroid acropachy and oncholysis, both of which can be present in Graves’ disease.
Feel the palms for warmth/sweat and check for erythema. Alternatively, the skin may be coarse and dry, with evidence of hair thinning.
Ask the patient to hold their hands outstretched, with their eyes closed and assess for a fast, fine resting tremor.
Thyroid acropachy: An extra-thyroid feature of Graves’ disease. It resembles finger clubbing, but is actually due to periosteal hypertrophy of the distal phalanges. Clinically, it is seen as a combination of clubbing and soft tissue swelling.
Resting tremor: This is a consequence of excess circulating T3 (metabolically active thyroxine) which potentiates the effects of catecholamines, thus increasing sympathetic activity.
Onycholysis: A painless detachment of the nail from the nail bed associated with sympathetic overactivity.
Take the radial pulse for 15 seconds to assess both rate and rhythm. Thyrotoxic patients are susceptible to atrial fibrillation, however they may just present with a sinus tachycardia. Hypothyroid patients may have bradycardia.
Measure the respiratory rate for 15 seconds to assess for tachypnoea.
Offer to check the patient’s blood pressure. Systolic hypertension may be identified in patients with hyperthyroidism.
Offer to test for Pemberton’s sign, which if present, is indicative of a mediastinal mass such as a thyroid goitre. This sign is elicited by asking the patient to raise their arms, which results in a progressively plethoric face.
Hypothyroidism can result in carpal tunnel syndrome. To check for this you may perform either Phalen’s manoeuvre or Tinel’s test.
On elevation of the arms, there is movement of the clavicles. If the patient has a significant goitre, the venous vasculature in the thoracic inlet is compressed against the goitre. Thus, there will be superior vena cava obstruction which, during the test, will result in a plethoric face due to venous engorgement.
In patients with carpal tunnel syndrome, these tests will elicit paraesthesia in the territory of the median nerve by irritating the impinged nerve:
Phalen’s manoeuvre is performed by asking the patient to hold their wrist in complete flexion for 30 seconds. This can be performed by pushing the dorsal surfaces of both hands together.
Tinel’s test involves tapping over the flexor retinaculum.
Eyes
In thyroid eye disease (also known as Graves’ opthalmopathy), there are a number of features which can be tested for.
Begin by looking for potential complications of severe exophthalmos. This includes conjunctival oedema (chemosis), conjunctivitis, corneal ulceration and evident lid retraction. Ensure you closely inspect from the side and then from above, by asking the patient to tilt their head back.
Assess eye movements in an H-pattern to look for any diplopia (as a result of exophthalmos), pain on eye movement or ophthalmoplegia .
Finally, assess for lid-lag . If positive, when asking the patient to follow your index finger as you move it from the upper to lower part of his/her visual field, there will be a delay between the descent of the upper eyelid in relation to that of the eyeball.
Exopthalmos (also known as ‘proptosis’): Anterior displacement and protrusion of the eye due to inflammatory infiltration of orbital contents, including the soft tissues and extraocular muscles. This can lead to inadequate lid closure and reduced surface wetting, which are the causes of many of the aforementioned complications, conjunctival oedema, conjunctivitis and corneal ulceration.
Lid-Lag is associated, as with many symptoms of thyrotoxicosis, with sympathetic over-activity.
Inspect the open mouth for an undescended thyroid, thyroglossal cyst or lingual goitre situated at the back of the tongue.
Neck
Inspection
Conduct a general inspection of the neck from the front and sides for a goitre, thyroidectomy scars or distended neck veins. Whilst inspecting the neck, ask the patient to protrude their tongue. Elevation of a neck mass during this action is indicative of a thyroglossal cyst. Then ask the patient to swallow a sip of water. Most goitres move upwards on swallowing, large goitres may be immobile and invasive thyroid cancers may fix the gland to surrounding structures.
Palpation
Repeat the process of asking the patient to protrude their tongue and swallow, but this time whilst palpating the thyroid bilaterally in a fixed position - again note the directionality of the mass’ movement. Prior to palpation, warn the patient this may be uncomfortable and be alert for any signs of diffuse tenderness (as seen in viral thyroiditis).
Separately palpate the left and right lobes. Note the size, shape and consistency of the goitre and/or any nodules.
Systematically palpate the cervical lymph nodes for lymphadenopathy. The presence of firm lymph nodes near a goitre is suggestive of malignancy.
Percussion
Percuss the sternum. Persistent dullness in this region suggests the thyroid gland may extend into the superior mediastinum or be entirely retrosternal.
Auscultation
Auscultate, individually, the two lobes of the thyroid with the bell of the stethoscope. A thyroid bruit may be audible and is indicative of abnormal hypervascularity. This can be accompanied with a palpable thrill.
Remember the thyroid is a butterfly-shaped endocrine gland with two symmetrical lobes that typically covers the 2nd-3rd tracheal rings. Hence, be sure to palpate the left and right lobes separately and be wary that normally the thyroid is impalpable. During palpation, ask the patient to sit with their neck muscles relaxed and stand behind him/her.
On another note, a goitre is merely an enlargement of the thyroid gland and not necessarily associated with thyroid dysfunction - most patients with a goitre are euthyroid.
Simple Goitres: Symmetrical, diffuse enlargement in the earlier stages, often becoming progressively nodular. Graves’ Disease: Symmetrical, diffuse enlargement, with extra-thyroid features. Plummer’s Disease: Single nodule palpable. Toxic Multinodular Goitre: Multiple nodules palpable. Thyroid Cancer: Hard nodules and often single lobe involvement.
Request the patient to stand unaided from a seated position, with their arms crossed. Be prepared to provide support to an unsteady patient. Patients who find this challenging may have proximal myopathy.
Assess the shins of the patient for pretibial myxoedema.
Test the deep tendon reflexes of the patient with the calcaneal reflex, to elicit signs of hyporeflexia or hyperreflexia.
Proximal myopathy is due to the excess thyroxine stimulated degradation of muscles fibres at the motor end plates of neuromuscular junctions.
Pretibial myxoedema is associated with Graves’ disease and appears as a raised, discoloured (pink/brown) indurated lesion. While this skin change is non-pitting in nature, hyperthyroid patients with superimposed heart failure may have additional pitting ankle oedema.
Completion
Complete the examination by offering to obtain a thyroid-focussed history, conduct thyroid function tests and perform a 12-lead electrocardiogram (ECG).
Thyroid function tests act a diagnostic tool, enabling the quantification of T3, T4 and TSH levels. Ensure you can interpret these results to suggest a plausible differential diagnosis.
A 12-lead ECG allows for the affirmation of potential sinus tachycardia, atrial fibrillation with a rapid ventricular response rate or bradycardia.
Interactive markscheme
When assessing each other, please click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I need to examine the thyroid gland in your neck today, would that be okay? Can I confirm your name and DOB? Thank you.”
"For the purpose of this examination the examiner will act as a chaperone."
Wash your hands.
Position the patient in a chair and ensure adequate exposure.
Ask about pain and discomfort - assess the patient's voice for hoarseness.
Inspect the patient (habitus, clothing, agitation) and their surroundings (medication, walking aid).
Inspect the hands for: sweatiness, palmar erythema, thyroid acropachy, oncholysis.
Assess for tremor.
Take the pulse for 15 seconds (assess for rate and rhythm).
Take the patient's blood pressure.
Optional: Offer to check for Pemberton's sign.
Inspect the eyes from the front and sides for: exophthalmos, chemosis, corneal ulceration.
Test eye movements for diplopia and ophthalmoplegia.
Specifically test for lid lag.
Inspect the mouth for an undescended thyroid or thyroglossal cyst.
Inspect the neck from the front and sides for: goitre, thyroidectomy scars, distended neck veins.
Whilst inspecting, ask the patient to swallow and stick out their tongue.
Palpate the thyroid.
Whilst palpating, ask the patient to swallow and stick out their tongue.
Palpate the cervical lymph nodes for lymphadenopathy.
Palpate the trachea for deviation.
Percuss the sternum for a retrosternal thyroid.
Auscultate the thyroid for bruits.
Palpate the shins for pretibial myxoedema.
Test for proximal myopathy by asking the patient to stand.
Assess the calcaneal reflex.
Thank the patient and finish.
"To conclude, I would like to take a full history, measure TFT levels and perform an ECG.”
