OSCE Checklist: Thyroid Status Examination

Introduction
1 Wash your hands and don PPE if appropriate

2 Introduce yourself to the patient including your name and role

3 Confirm the patient's name and date of birth

4 Briefly explain what the examination will involve using patient-friendly language

5 Gain consent to proceed with the examination

6 Ask the patient to sit on a chair for the assessment

7 Adequately expose the patient’s neck and upper sternum

8 Ask if the patient has any pain before proceeding

9 Gather equipment

General inspection
10 Inspect the patient whilst at rest, looking for clinical signs suggestive of underlying
pathology

Hands
11 Palpate the patient’s radial pulse assessing rate and rhythm

Face
12 Inspect the patient’s face for clinical signs suggestive of thyroid pathology (dry skin,
excessive sweating, eyebrow loss).
13 Inspect the patient's eyes for evidence of lid retraction, inflammation and exophthalmos

14 Assess for eye movement abnormalities

15 Assess for lid lag

Thyroid inspection
16 Inspect the midline of the neck for evidence of thyroid enlargement, lumps or scars

17 Ask the patient to swallow some water and repeat inspection

18 Ask the patient to protrude their tongue and repeat inspection

Thyroid palpation
19 Palpate the patient's thyroid gland assessing size, symmetry and consistency. Also note any
masses present in the thyroid tissue.
20 Ask the patient to swallow some water whilst you feel for symmetrical elevation of the
thyroid lobes
21 Ask the patient to protrude their tongue whilst you palpate

Lymph node palpation

22 Palpate local lymph nodes to assess for lymphadenopathy

Trachea
23 Inspect for tracheal deviation

Percussion of the sternum

24 Percuss downwards from the sternal notch for evidence of retrosternal dullness

Auscultation of the thyroid gland

25 Auscultate each lobe of the thyroid for a bruit

Special tests
26 Assess biceps reflex

27 Inspect for pretibial myxoedema

28 Ask the patient to stand with their arms crossed to assess for proximal myopathy

To complete the examination…

29 Explain to the patient that the examination is now finished

30 Thank the patient for their time

31 Dispose of PPE appropriately and wash your hands

32 Summarise your findings

33 Suggest further assessments and investigations (e.g. thyroid function tests, ECG, ultrasound
scan)

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 OSCE Checklist: Examination of the Thyroid

Introduction
Introduce yourself
Wash hands
Briefly explain to the patient what the examination involves
Ask the patient to sit of a chair
General Inspection

Clinical signs of
- Alopecia or vitiligo
- Abnormal temperature regulation
Hands
Nail bed and fingers
- Thyroid acropachy
- Onycholysis
Palmar erythema
Fine tremor
Radial pulse
Eyes
Proptosis or exophthalmos
Eye movements
Lid retraction and lid-lag
Convergence
Neck and Face
Initial inspection
Palpate the thyroid gland
- Size
- Symmetry
- Tenderness
- Lumps
Palpate the lymph nodes
Tracheal deviation
Percuss for retrosternal dullness
Auscultation of the gland
Legs
Evidence of pretibial myxoedema
Test the patella reflex
Sit-to-stand test
Completing the Examination
Thank the patient
To complete the examination:
- Inspect for evidence of gynaecomastia
- Perform a cardiovascular examination and blood pressure reading
Endocrine
Thyroid Examination

Thyroid Examination
General inspection
Look for signs of:
Hyperthyroidism: Hypothyroidism:
Weight loss. Overdressed.
Anxiety. Facial maxiedema.
Frightened facies of Look for signs of mental and physical
thyrotoxicosis. sluggishness.
Sweaty.

Neck Inspection
1-Look at the front and sides
of the neck .
2- Ask the patient to swallow
and watch the neck
movement.
3- Ask the patient to put out
the tongue .
4- Describe the swelling .
5- Skin status .
- Look for localized or general masses and
swelling.
-Enlargement (pseudogoitre) can occur as a
result of the presence of a fat pad in the
anterior and lateral part of the neck.
- Enlargement of the gland called goitre
should be apparent on inspection .
- Only a goiter or thyroglossal cyst will
rise during swallowing.
- if the mass moves , it is most likely a
thyroglossal cyst , but if did not it may be a
thyroid swelling .
-Redness of the skin over the gland occurs
in cases of suppurative thyroiditis .
6- Old scar . -Thyroidectomy .
7- Thyroid cartilage: Present or - in healthy people the line between the
not , deviated or not. cricoid cartilage and the suprasternal notch
should be straight.
- An outward bulge suggests the presence
of a goitre.

8- Dilated veins over the upper - due to obstruction of thoracic inlet

part of the chest wall (often
accompanied by filling of the
external jugular vein ).
Neck Palpation
From behind
1- Flex the neck slightly , put
your thumbs behind the neck
and the rest of your fingers in
front.
2- Feel one side at a time, use
one hand to steady the gland
and the other to palpate.
-to feel the thyroid lobes.
Consider the following:
- Size: Feel particularly carefully for a lower
border, because its absence suggests
retrosternal extension.
-Shape: note whether the gland is uniformly
enlarged or irregular and whether the
isthmus is affected.
- Nodules: if it is palpable , determine its
location, size, consistency, tenderness and
mobility. Also if the whole gland feels
nodular (multinodular goitre)
- Consistency:
Soft: is normal
Firm: in simple goitre
rubbery hard:
thyroiditis.
stony hard node: in carcinoma.
calcification: in a cyst fibrosis or

- Tenderness: this may be a feature of

thyroiditis or less often of a bleed into a
cyst or carcinoma.
- Mobility: carcinoma may tether the
gland.

3-Ask the patient to swallow
during palpation .
4- Palpate the cervical and
supraclavicular lymph nodes.
From the Front
1-Palpate again.
2- Note the position of the
trachea.
Neck Percussion
1- over sternum .
2- The clavicle .
3- Supraclavicular fossa .
Neck Auscultation
1- Listen over each lobe for a
bruit (systolic bruit )
2- listen for stridor in lateral
lobes.
1-Inspect for palmar erythema
and feel the palms for warmth
and sweatiness.
2- Take the pulse: rate and
rhythm .
- Thrill: this may be palpable over the gland
as in thyrotoxicosis.
-Normal thyroid gland is not palpable.
These may be involved in carcinoma of the
thyroid.
- The same as from the behind.
- displaced by a retrosternal gland.
-Looking for mass extending.
- This is a sign of increased blood supply,
which may occur in hyperthyroidism, or from
the use of anti-thyroid drugs.
- a carotid bruit (louder over the carotid
itself).
- venous hum
- in Goitre
Hand
-due to sympathetic overactivity.
-Note the presence of :
Sinus tachycardia (sympathetic
overdrive)
Atrial fibrillation (due to a shortened
refractory period of atrial cells related
to sympathetic drive and hormone-
induced changes).
pulse collapsing due to a high cardiac
output in hyperthyroidism.
 small volume and slow in
hypothyroidism .
3-look for a fine or fast tremor. -due to sympathetic overactivity in
hyperthyroidism
4- Look at the nails for
onycholysis (where there is
separation of the nail from its
bed)

5- Inspect for thyroid -seen rarely but not with

Acropathy (soft-tissue swelling other causes of thyrotoxicosis.
of the hands and clubbing of
the fingers).

6- peripheral cyanosis -due to reduced cardiac output in

hypothyroidism .
7- swelling of the skin and may - Hypothyroidism
appear cool and dry and pale.

Arm
1- Ask the patient to raise the - In hyperthyroidism.
arms above the head to test
for proximal myopathy.
2- Tap the arm for abnormal -Hyporeflexia: with hypothyroidism
briskness reflexes. -Hyperreflexia: with hyperthyroidism.
Eyes
1- -
for Exophthalmos .

2- Examine for the (1) chemosis: oedema of

complications of the conjunctiva and
Exophthalmos injection of the
sclera.
(2) Conjunctivitis.
(3) corneal ulceration: due to inability to
close the eyelids.
(4) optic atrophy: rare and possibly due
to optic nerve stretching.

3- lid retraction
sign)
4-
by asking the patient to follow
your finger as it descends at a
moderate rate from the upper
to the lower part of the visual
field.
5- Inspect the eyes for
periorbital oedema.
1- Gynaecomastia.
2- Examine the heart for
systolic flow murmurs
1- Look for pretibial
myxedema.
2- Test for proximal myopathy.
(5) ophthalmoplegia: The inferior rectus
muscle power tends to be lost first,
and later convergence is weakened.
-in hyperthyroidism.
- Descent of the upper lid lags behind
descent of the eyeball.
-in hyperthyroidism
-Hypothyroidism.
Chest
-in hyperthyroidism.
- due to increased cardiac output.
Legs
- caused by mucopolysaccharide
accumulation.
-
hypothyroidism
-Hyperthyroidism.
 3-knee reflex -Hyperreflexia: in Hyperthyroidism. -
Contraction followed by delayed relaxation
of the foot in hypothyroidism.

DIAGNOSTIC TESTING:
Thyroid function test.
Blood sugar.
Ultrasound.

Endocrine Done by: Nouf Alrushaid

Revised by: Areej AlWehaib
Thyroid Examination Team Leaders: Abdulrahman Bahkley & Sara Habis