The Thyroid Examination: What the OSCE Is Really Testing
The thyroid examination station tests two skills simultaneously: your ability to examine a neck lump systematically and your ability to assess the functional thyroid status of the patient. Examiners want to see that you can characterise the gland (size, nodularity, tenderness, mobility, bruit) and then step back and look at the whole patient for signs of hypo- or hyperthyroidism.
The most common OSCE scenario is a patient with a goitre — diffuse or nodular — and you must be able to describe it accurately, interpret the findings, and give a differential diagnosis.
💡 Tip
Setup: Ask the patient to sit in a chair with their neck exposed. Have a glass of water on a table in front of them — you'll ask them to swallow during the examination. Position yourself behind the patient for palpation.
Part 1: Examine the Neck Lump Systematically
Inspect from the Front
Look for:
- Visible swelling in the anterior triangle, specifically over the thyroid gland (lower anterior neck, either side of the trachea)
- Symmetry: Diffuse (goitre) vs unilateral (solitary nodule, multinodular goitre with dominant nodule)
- Overlying skin: Erythema, scars (previous thyroidectomy)
- Tracheal deviation: Suggests retrosternal extension or a large unilateral mass
- Pemberton's sign: Ask the patient to raise their arms above their head — flushing, facial plethora, and distended neck veins indicate retrosternal goitre compressing the thoracic inlet
Ask the patient to swallow (give them the water). A thyroid lump moves upwards on swallowing — this is because the thyroid is enclosed within the pretracheal fascia, which is attached to the larynx. A midline swelling that moves up on swallowing but not on tongue protrusion is a thyroglossal cyst, not thyroid tissue.
Ask the patient to protrude their tongue — a thyroglossal cyst moves upward; a thyroid nodule does not.
Palpate from Behind
Stand behind the patient and place your fingertips symmetrically over the thyroid gland (below the thyroid cartilage, either side of the trachea):
- 1Size: Estimate lobar enlargement
- 2Consistency: Soft (colloid goitre), firm (Hashimoto's), hard (malignancy, calcification)
- 3Surface: Smooth (diffuse goitre, Graves') vs nodular (multinodular goitre) vs solitary nodule
- 4Tenderness: Painful = De Quervain's thyroiditis or haemorrhage into nodule
- 5Mobility: Does it move with swallowing? (Confirm what you saw on inspection) Is it fixed? (Suggests malignancy invading surrounding structures)
- 6Lower border: Can you get below it? If not, suggest retrosternal extension
Also check:
- Trachea: Central or deviated?
- Cervical lymph nodes: Anterior and posterior chains, submandibular, submental — lymphadenopathy raises concern for papillary thyroid carcinoma
⚠️ Red Flag
Red flags for thyroid malignancy (the "HARD" mnemonic):
- Hard consistency
- Adhesion / fixation to surrounding structures
- Recurrent laryngeal nerve involvement (hoarse voice)
- Dysphagia or rapid growth
Any single one of these features in a thyroid nodule requires urgent referral under the 2-week-wait pathway.
Percuss and Auscultate
- Percuss the sternum: Dullness extending into the upper chest suggests retrosternal goitre
- Auscultate over the thyroid lobes: A bruit indicates increased vascularity — classically heard in Graves' disease (active hyperthyroidism)
🧠 Mnemonic
Graves' = Bruit: The hypermetabolic state of Graves' disease drives increased blood flow through the thyroid, generating a continuous bruit audible with the bell of the stethoscope.
Part 2: Assess Thyroid Status
After examining the gland, you must assess whether the patient is euthyroid, hyperthyroid, or hypothyroid. Work systematically from hands to eyes.
Hands
| Sign | Hyperthyroid | Hypothyroid |
|---|---|---|
| Temperature | Warm, sweaty | Cool, dry |
| Tremor | Fine tremor (paper over outstretched hands) | Slow, none |
| Pulse | Tachycardia, AF | Bradycardia |
| Palmar erythema | Present | Absent |
| Nails | Onycholysis (Plummer's nails) | Brittle, dry |
Face
| Sign | Hyperthyroid | Hypothyroid |
|---|---|---|
| Appearance | Anxious, agitated | Puffy, pale, periorbital oedema |
| Hair | Fine, thin | Coarse, brittle, loss of outer 1/3 eyebrow |
| Eyes | Exophthalmos, lid lag, lid retraction (Graves') | Xanthelasma (dyslipidaemia) |
Assess the eyes specifically:
- Exophthalmos (proptosis): Forward protrusion of the globe — look from the side and from above. Only in Graves' disease (autoimmune — TSI antibodies cause retro-orbital inflammation)
- Lid retraction: Upper lid above the limbus — gives a staring appearance
- Lid lag: Ask the patient to follow your finger downward — the upper lid lags behind the iris, revealing sclera
- Ophthalmoplegia: Ask the patient to follow your finger in all directions — restriction of upward gaze is most common
💎 Clinical Pearl
Lid lag vs lid retraction: Lid retraction is constant (upper lid sits too high at rest). Lid lag only appears on downward gaze. Both are due to sympathetic overstimulation of the superior tarsal muscle (Müller's muscle) — present in any cause of hyperthyroidism, not just Graves'. Exophthalmos is specific to Graves' (autoimmune infiltration of retro-orbital tissue).
Legs and Reflexes
- Pretibial myxoedema: Non-pitting, orange-peel skin over the shins — despite the name, only occurs in Graves' disease (hyperthyroidism), not hypothyroidism
- Reflexes: Brisk with fast relaxation (hyperthyroid) vs slow relaxation — "hung-up" reflexes (hypothyroid)
- Proximal myopathy: Ask the patient to rise from a chair without using their hands (seen in hyperthyroidism)
🧠 Mnemonic
Signs of hypothyroidism — "MOIST CLAD":
- Myxoedema (dry, doughy skin, periorbital)
- Outer 1/3 eyebrow loss (Queen Anne's sign)
- Increased weight / constipation / cold intolerance
- Slow pulse (bradycardia)
- Tiredness, depression
- Coarse hair and dry skin
- Low mood / cognitive slowing
- Anaemia (normocytic or macrocytic with B12 deficiency)
- Delay in reflexes (hung-up ankle jerks)
Differential Diagnosis of a Neck Lump
A systematic approach to any neck lump — not all anterior swellings are thyroid:
| Region | Causes |
|---|---|
| Midline | Thyroid, thyroglossal cyst, dermoid cyst, lymph node |
| Anterior triangle | Lymph node, branchial cyst, carotid body tumour, submandibular gland |
| Posterior triangle | Lymph node, cervical rib, subclavian artery aneurysm |
| Any site | Lipoma, sebaceous cyst, metastatic lymph node |
How to Present Your Findings
"On general inspection the patient appeared clinically euthyroid. In the neck there was a diffusely enlarged smooth goitre visible at rest which moved upward on swallowing, consistent with thyroid tissue. It did not move on tongue protrusion. On palpation the gland was smooth, non-tender, symmetrically enlarged, and soft in consistency. There was no lymphadenopathy and I could get below the lower border. I heard no bruit on auscultation. Systematic assessment showed no tremor, warm dry hands, heart rate regular at 70, no eye signs, and normal reflexes. The overall impression is a diffuse smooth euthyroid goitre. The differential includes simple colloid goitre, early Hashimoto's thyroiditis, or iodine deficiency. I would investigate with TFTs, thyroid antibodies, and ultrasound of the neck."
Common Examiner Follow-Up Questions
"What blood tests would you request and what results would you expect in Graves' disease?"
"I would request thyroid function tests — in Graves' disease I would expect a suppressed TSH (typically undetectable, <0.01 mU/L) with elevated free T4 and usually elevated free T3. I would also check TSH receptor antibodies (TRAb or TSI) which are positive in over 95% of Graves' disease and help confirm the diagnosis. If there is any diagnostic uncertainty or a nodule is present, I would arrange a thyroid isotope scan — Graves' shows diffuse uptake; a toxic nodule shows a 'hot' area with suppression of the remainder."
"What is the management of hyperthyroidism?"
"Management depends on the cause and severity. Initial medical treatment with a thionamide — carbimazole first-line in the UK, propylthiouracil in pregnancy or as second line — either titrated to TFTs or as block-and-replace with levothyroxine. Beta-blockers (propranolol) for symptomatic relief of tachycardia and tremor. Definitive treatment options are radioiodine ablation (contraindicated in pregnancy, active eye disease) or thyroidectomy (preferred in large goitre, malignancy concern, or failed medical treatment). All options have risks — radioiodine commonly causes hypothyroidism requiring lifelong levothyroxine."
"What is a thyroid storm and how is it managed?"
"Thyroid storm is a life-threatening exacerbation of hyperthyroidism, typically precipitated by surgery, infection, or radioiodine in an inadequately prepared patient. Features include hyperpyrexia, severe tachycardia, AF, agitation, confusion, and potentially coma. It is a medical emergency managed in ITU: IV propylthiouracil or carbimazole to block synthesis, Lugol's iodine (given 1 hour after thionamide) to block release, IV hydrocortisone (blocks peripheral conversion of T4 to T3), beta-blockade for tachycardia, active cooling, and treatment of the precipitant."