Introduction
The thyroid history OSCE tests your ability to elicit symptoms of thyroid dysfunction and distinguish hyperthyroidism from hypothyroidism. A neck lump station may also require a focused goitre history. Examiners reward systematic symptom coverage, ICE, and red flag identification.
💎 Clinical Pearl
Start open: "Can you tell me what's been bothering you?" Then use a systematic symptom screen — both hyper and hypothyroidism have overlapping features (neck swelling, fatigue) so covering both directions is essential.
Thyroid Symptom Screen — Hyper vs Hypo
Hyperthyroidism Symptoms — SWEATING
🧠 Mnemonic
SWEATING:
Sweating (heat intolerance)
Weight loss (increased appetite)
Emotional lability, anxiety, irritability
Arrhythmia — palpitations (AF in elderly)
Tremor (fine resting/postural tremor)
Insomnia
Neck swelling (goitre)
Gastrointestinal: diarrhoea, increased bowel frequency
Hypothyroidism Symptoms — FATIGUE
🧠 Mnemonic
FATIGUE:
Fatigue and lethargy
Aching muscles (myopathy), slow relaxing reflexes
Thinking slowly (brain fog, memory impairment)
Intolerance to cold
Gain of weight (decreased appetite)
Under-active bowels (constipation)
Edema (periorbital puffiness, dry puffy skin), hair loss
Comparing the Two
| Feature | Hyperthyroidism | Hypothyroidism |
|---|---|---|
| Weight | Loss despite normal or increased appetite | Gain despite normal or decreased appetite |
| Temperature preference | Intolerant of heat | Intolerant of cold |
| Bowels | Diarrhoea, increased frequency | Constipation |
| Mood | Anxious, irritable, emotionally labile | Low mood, depression, brain fog |
| Heart | Palpitations, tachycardia, AF | Bradycardia |
| Skin and hair | Warm moist skin, hair thinning | Dry coarse skin, hair loss, eyebrow loss (lateral third) |
| Reflexes | Brisk, hyperreflexia | Slow-relaxing (hung-up) reflexes |
Goitre History
If the patient presents with a neck swelling, take a focused goitre history:
Character of the Swelling
- When first noticed? Sudden or gradual?
- Growing? Rate of growth?
- Painful or painless?
Compressive Symptoms (red flags)
⚠️ Red Flag
These suggest a large goitre or malignancy:
- Dysphagia (difficulty swallowing)
- Dysphonia or voice change (recurrent laryngeal nerve involvement)
- Stridor (tracheal compression)
- Dyspnoea
- Pemberton's sign: raising both arms above head causes facial flushing and JVP rise (superior vena cava obstruction from retrosternal goitre)
Thyroid Cancer Red Flags
⚠️ Red Flag
- Rapid enlargement
- Hard, irregular, fixed swelling
- Cervical lymphadenopathy
- Voice hoarseness
- Dysphagia or stridor
- Previous head or neck irradiation
- Family history: MEN2 (medullary thyroid cancer), familial papillary thyroid cancer
- Age under 20 or over 65 with new goitre
Graves' Disease Specific Features
If hyperthyroidism is suspected, ask about features specific to Graves' disease:
- Exophthalmos (eye protrusion): "Have your eyes changed? Do they feel dry or gritty?"
- Diplopia or visual change (ophthalmoplegia)
- Pretibial myxoedema (rare): "Any skin changes on your legs?"
- Family history of autoimmune thyroid disease or other autoimmune conditions
Past Medical History and Medication
- Previous thyroid problems or surgery
- Radioiodine treatment
- Other autoimmune conditions: type 1 diabetes, rheumatoid arthritis, vitiligo, pernicious anaemia (associated with autoimmune thyroid disease)
- Medications: amiodarone (causes both hyper and hypo), lithium (causes hypothyroidism), contrast media
- Iodine exposure: recent contrast media, kelp supplements
- Radiation to neck
ICE and Closing
- "What do you think might be causing these symptoms?"
- "Is there anything in particular you were worried this could be?"
- "How are these symptoms affecting your daily life and work?"
"What are the symptoms of hyperthyroidism?"
Hyperthyroidism causes: weight loss with increased appetite, heat intolerance and sweating, palpitations and tachycardia (AF in elderly), anxiety and irritability, fine tremor, diarrhoea, insomnia, goitre, and in Graves' disease specifically, exophthalmos and pretibial myxoedema. The SWEATING mnemonic covers the core features.
"What are the features of hypothyroidism that examiners commonly ask about?"
Hypothyroidism causes: fatigue and lethargy, weight gain with decreased appetite, cold intolerance, constipation, dry coarse skin, hair loss (including the lateral third of eyebrows), bradycardia, low mood and cognitive slowing, periorbital puffiness, and slow-relaxing (hung-up) reflexes. The FATIGUE mnemonic covers the key features.
"What red flags in a thyroid history suggest malignancy?"
Red flags suggesting thyroid malignancy include: rapid enlargement of a thyroid swelling, hardness and fixation of the gland, cervical lymphadenopathy, voice hoarseness (recurrent laryngeal nerve involvement), dysphagia or stridor (compressive symptoms), previous neck irradiation, family history of MEN2 or familial thyroid cancer, and age under 20 or over 65 with a new goitre.
"Which medications commonly affect thyroid function?"
Amiodarone (40% iodine by weight) causes both hyperthyroidism and hypothyroidism. Lithium inhibits thyroid hormone release and causes hypothyroidism. IV iodinated contrast can trigger thyrotoxicosis in susceptible patients. Interferon-alpha and immune checkpoint inhibitors (cancer immunotherapy) can cause autoimmune thyroiditis. Always take a thorough drug history in any thyroid history.
Related guides: Thyroid Examination OSCE | Cognitive Assessment OSCE | Blood Results Interpretation OSCE