Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Sit patient in the middle of the room (so you can stand behind them)
• Expose patient’s neck

General inspection

• Patient: well/unwell, anxious/nervous, hot/cold, facial complexion (myxoedematous, flushed), obvious muscle wasting, BMI, obvious thyroid swellings, dry hair/waxy skin
• Around bed: excess clothes

Hands

• Fine tremor: ask patient to stretch out arms and hands with fingers straight and separated. A tremor is more easily visualised with a sheet of paper resting on top of the patient’s hands (fine tremor = thyrotoxicosis).
• Nails: thyroid acropachy (Graves’ disease), onycholysis (thyrotoxicosis)
• Palms: cold and dry (hypothyroidism), moist and sweaty (thyrotoxicosis), palmar erythema (thyrotoxicosis)
• Pulse (tachycardia and AF in thyrotoxicosis)

Face

• Generally: waxy pale skin, hair thinning (including lateral third of eyebrows), myxoedema* (all signs of hypothyroidism)
• Eyes
  • Lid retraction of upper eye-lid (thyrotoxicosis)
  • Exophthalmos (sclera visible above and below iris)
  • Proptosis (forward protrusion of eye; inspect from above and side)
  • Chemosis/conjunctival oedema 
• Extra-ocular muscles:
  • Perform H-test and ask about diplopia to test for ophthalmoplegia
  • Test central vertical eye movement (‘lid lag’ on downward vertical gaze = thyrotoxicosis)

Neck

• Inspection (from anteriorly)
  • Swellings and scars
  • Ask patient to swallow (thyroid and thyroglossal cysts move on swallowing)
  • Stick out tongue (thyroglossal cysts move on tongue protrusion)
  • Place their hands above their head (Pemberton’s sign = retrosternal goitre compresses superior vena cava and results in venous congestion)
• Palpation (from posteriorly)
  • Palpate thyroid gland (over 2^nd, 3^rd and 4^th tracheal cartilages), including feel while patient swallows and sticks out tongue
  • Full cervical lymph node exam

• If you feel a mass/swelling,note its characteristics (SSSCCCTTT)
  • Size, Shape, Surface, Consistency, Contours, Colour, Temperature, Tenderness, (Transillumination not required for thyroid)

• Percussion over sternum: for retrosternal goitre
• Auscultation: thyroid bruit over each lobe

Finally

• Proximal myopathy: test resisted shoulder abduction, then ask patient to stand up from chair with arms crossed (hypothyroidism or hyperthyroidism)
• Reflexes (brisk in hyperthyroidism; slow-relaxing in hypothyroidism)
• Look for pretibial myxoedema (Graves’ disease)

To complete

• Thank patient
• Summarise and suggest further investigations you would consider after a full history (e.g. TFTs, thyroid USS)

Questions

Now you’re ready for some OSCE stations!

1. Normal thyroid exam
2. Graves’ disease
3. Hashimoto’s thyroiditis
4. Our subscribers enjoy hundreds of stations!

Picture references

Exophthalmos: Jonathan Trobe, M.D. The Eyes Have It 2011. Licensed under the Creative Commons Attribution 3.0 Unported license