Hyperthyroidism: extra-thyroidal manifestations OSCE checklist

1. Hands and arms

• Warm, moist palms
• Fine postural tremor
  • Ask patient to stretch arms forward, fingers spread
  • Place a sheet of paper on hands to make tremor more visible
• Palmar erythema
• Sweaty hands
• Onycholysis, nails lifting from nail bed
• Thyroid acropachy: digital clubbing with soft-tissue swelling of fingers, rare
• Proximal myopathy
  • Ask patient to abduct both arms against resistance
  • Or ask them to rise from a chair without using arms

2. Pulse and cardiovascular system

• Check radial pulse for rate and rhythm
• Tachycardia
• Irregularly irregular rhythm suggesting atrial fibrillation
• Check blood pressure for systolic hypertension and wide pulse pressure
• Look for heart-failure features if severe disease: peripheral edema, raised JVP, basal crackles

3. Eye examination

• Stare: widened palpebral fissures
• Lid retraction: upper lid abnormally high at primary gaze
• Lid lag: ask patient to follow your finger slowly downward, upper eyelid lags behind the globe
• Exophthalmos/proptosis: inspect from above and side
• Periorbital edema
• Conjunctival injection or chemosis
• Restriction of eye movements, especially upgaze
• Diplopia: ask about double vision
• Visual acuity and colour vision if orbitopathy suspected
• Red flags for urgent ophthalmology assessment: reduced visual acuity/colour vision, visual-field defect, corneal exposure, severe pain, or marked ophthalmoplegia

4. Legs and skin

• Inspect shins for pretibial myxoedema
  • Non-pitting, firm, waxy or peau d’orange thickening, sometimes discoloured
• Look for diffuse warm, moist skin
• Check for hair thinning/fine hair
• Assess for non-pitting peripheral edema

5. Neuromuscular and neuropsychiatric features

• Fine tremor
• Brisk reflexes/hyperreflexia
• Proximal muscle wasting or weakness
• Restlessness, anxiety, irritability, emotional lability
• Ask about sleep disturbance

6. General systemic features to ask about

• Weight loss despite increased appetite
• Heat intolerance and excessive sweating
• Palpitations, exertional dyspnea, chest pain
• Increased bowel frequency or diarrhoea
• Menstrual irregularity, reduced fertility
• Reduced libido or erectile dysfunction
• In older adults: weight loss, atrial fibrillation, and heart failure may occur with few classical adrenergic signs, termed apathetic hyperthyroidism.

Closing OSCE statement

“This patient has features of thyrotoxicosis, including [tachycardia/tremor/warm moist hands]. The presence of [diffuse goitre with bruit, orbitopathy, pretibial myxoedema, or acropachy] would specifically support Graves disease. I would complete cardiovascular assessment, check thyroid function tests, thyroid antibodies, and arrange urgent ophthalmology review if there were visual red flags.”

Hyperthyroidism OSCE Checklist

1. General inspection

• Comfortable at rest or agitated/anxious?
• Body habitus and obvious weight loss
• Sweaty appearance, warm environment intolerance
• Visible goitre or neck scar
• Eye prominence or redness
• Mobility aids or signs of proximal weakness

2. Hands and arms

• Warm, moist hands
• Palmar erythema
• Fine tremor: arms outstretched, fingers spread, place paper on hands
• Onycholysis
• Acropachy: clubbing and swollen distal digits, rare Graves feature
• Pulse: rate and rhythm
• Check for atrial fibrillation
• Proximal myopathy: shoulder abduction against resistance or rise from chair
• Brisk reflexes

3. Face and eyes

• Stare
• Lid retraction
• Lid lag: ask patient to follow your finger slowly downward
• Proptosis/exophthalmos: inspect from front, side, and above
• Periorbital puffiness
• Conjunctival injection or chemosis
• Extraocular movements and diplopia
• If orbitopathy suspected: visual acuity, colour vision, visual fields

4. Neck and thyroid

• Inspect for diffuse or nodular swelling
• Palpate thyroid from behind: size, symmetry, nodules, consistency, tenderness, movement on swallowing
• Check for cervical lymphadenopathy
• Percuss for retrosternal extension if indicated
• Auscultate for a thyroid bruit
  • Suggests a vascular Graves goitre

5. Legs and cardiovascular assessment

• Pretibial myxoedema: non-pitting, waxy thickening over shins
• Peripheral edema
• Blood pressure: systolic hypertension/wide pulse pressure
• Complete cardiovascular examination if tachycardia, AF, breathlessness, or edema

6. Ask about symptoms

• Weight loss despite increased appetite
• Heat intolerance and sweating
• Palpitations, dyspnoea, chest pain
• Tremor, anxiety, irritability, poor sleep
• Increased bowel frequency or diarrhoea
• Menstrual disturbance, reduced libido, erectile dysfunction
• Eye pain, grittiness, watering, photophobia, diplopia, visual change
• Drug history: amiodarone, thyroid hormone, iodine exposure
• Family/personal autoimmune history

7. To complete the assessment

• Thyroid function tests: TSH, free T4, free T3
• TSH-receptor antibodies if Graves disease suspected
• ECG for tachyarrhythmia/atrial fibrillation
• Consider thyroid ultrasound or radionuclide scan according to cause
• Urgent senior review if thyroid storm or decompensated cardiac disease is suspected

OSCE summary statement

“This patient has clinical features of thyrotoxicosis, including [findings]. The presence of diffuse goitre with bruit, orbitopathy, pretibial myxoedema, or acropachy would support Graves disease. I would confirm with thyroid function tests, assess cardiovascular complications with an ECG, and arrange urgent ophthalmology assessment if there are visual red flags.”