Thyroid examination — goitre and tremor
PLAB 2 & PRES 3 · endocrine · medium · 10 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Ms Chloe Bennett, 34, has noticed a swelling in her neck and has been losing weight despite a good appetite. The nurse has recorded: pulse 104 and regular, blood pressure 132/68 mmHg, temperature 37.2 °C. Please perform a thyroid examination, including an assessment of thyroid status. Present your findings to the examiner, then discuss the likely diagnosis and your management plan.
What examiners look for
A thyroid examination has two halves and examiners mark both: the gland (size, symmetry, consistency, movement, bruit, nodes) and the status (hands, pulse, eyes, reflexes, myopathy). A candidate who describes the lump beautifully but never takes the pulse has done half the station. Movement is the neck-lump discriminator: thyroid masses rise on swallowing because the gland is strapped to the larynx, thyroglossal cysts also rise on tongue protrusion, and lymph nodes do neither. Two thirty-second tests sort most of the differential before palpation begins. Palpate from behind with the neck slightly flexed — standing in front and prodding is both technically worse and a visible technique error examiners notice immediately. Eye signs belong to Graves disease alone among the causes of thyrotoxicosis: lid retraction, exophthalmos and lid lag. Their presence converts "overactive thyroid" into a specific diagnosis, so look at the eyes from the front, the side and above, and test lid lag deliberately. A thyroid bruit is a flow sign of a hyperactive gland — you only find it if you listen, and it supports Graves or toxic nodular disease over thyroiditis. The tremor paper trick is not theatre: a fine thyrotoxic tremor can be invisible until a sheet of paper on the outstretched hands starts to quiver, and demonstrating it is a named technique in the guides. Carbimazole counselling is a safety mark, not a courtesy: sore throat, mouth ulcers or fever can mean agranulocytosis, and the instruction — stop the drug, same-day blood count — must be given before the first prescription, with baseline full blood count and liver function checked first. End every thyroid station by reconciling the patient's two fears separately: the lump fear (cancer) and the symptom fear (why is my body racing). They need different answers, and this patient asked both.
Guideline references
Practise this station
Role-play it with an AI patient and get feedback against the full marking scheme. Create a free account — 3 stations per month free.