Step-by-Step OSCE Guide

GETTING STARTED

1. Perform hand hygiene and don PPE if required.
2. Introduce yourself: “Hi, I’m Jamie, one of the advanced clinical practitioners.”
3. Confirm the patient’s full name and date of birth.
4. Briefly explain: “I’d like to examine your thyroid gland today – this includes examining your neck, face, hands, and some reflexes.”
5. Gain verbal consent and offer a chaperone if appropriate.
6. Position the patient seated upright on a chair.
7. Ask if the patient is in any discomfort before you begin.

GENERAL INSPECTION

8. Observe the patient at rest for signs of thyroid dysfunction:
   – Hyperthyroid: restlessness, sweating, tremor, weight loss.
   – Hypothyroid: dry skin, slowed movements, weight gain.

HANDS

9. Inspect the hands for dry skin, palmar erythema, or fine tremor.
10. Palpate the radial pulse – assess rate and rhythm (tachycardia suggests hyperthyroidism).
11. Look for signs of thyroid acropachy or onycholysis (Plummer’s nails).

FACE AND EYES

12. Inspect for dry skin, thinning of eyebrows (especially lateral third), or facial puffiness.
13. Examine the eyes for lid retraction, proptosis (exophthalmos), conjunctival injection.
14. Perform tests for lid lag and impaired eye movements – note any diplopia or pain.

NECK EXAMINATION

15. Inspect the neck from the front and side for swelling, scars or asymmetry.
16. Ask the patient to swallow water and observe for thyroid movement.
17. Ask them to protrude the tongue – thyroglossal cysts may move upward.

PALPATION

18. Gently palpate the thyroid from behind using both hands.
19. Assess the gland for size, nodules, tenderness, and texture.
20. Ask the patient to swallow again while palpating – check for symmetrical movement.
21. Ask them to protrude the tongue during palpation for midline movement.

LYMPH NODES

22. Palpate anterior and posterior cervical lymph nodes for enlargement.

TRACHEA AND PERCUSSION

23. Inspect for tracheal deviation.
24. Percuss over the upper sternum – dullness may suggest a retrosternal goitre.

AUSCULTATION

25. Auscultate over the thyroid lobes – a bruit may indicate increased vascularity (e.g. Graves’ disease).

SPECIAL TESTS

26. Check for delayed relaxation of biceps reflex (suggests hypothyroidism).
27. Inspect for pretibial myxoedema.
28. Ask the patient to stand from seated with arms crossed to assess for proximal myopathy.

TO COMPLETE THE EXAM

29. Thank the patient and offer help to redress.
30. Dispose of PPE and wash your hands.
31. Summarise your findings clearly.
32. Suggest next steps:
    – Thyroid function tests (TFTs)
    – Thyroid ultrasound
    – ECG if tachycardia present

A thorough thyroid exam goes beyond the neck. Be systematic and always relate physical signs back to the physiology. Keep your radar up for subtle changes.