Phys · general-medicine
Thyroid Status and Neck Examination — DCE Short-Case Routine
Also known as thyroid examination · thyroid status examination · neck examination · goitre examination · thyroid short case · DCE thyroid · PACES thyroid examination · examine the thyroid · Graves orbitopathy examination · thyroid system assessment
Consultant-physician guide to the systematic thyroid status examination for the DCE short case: the nine-step routine performed from behind the patient (general inspection, hands, pulse, eyes, neck inspection, neck palpation, percussion, auscultation, reflexes and legs), the hyperthyroid and hypothyroid clinical phenotypes, the Graves-specific eye and skin signs (exophthalmos, lid lag, lid retraction, ophthalmoplegia, thyroid acropachy, pretibial myxoedema), the NOSPECS and CAS scoring systems, the model presentation template, the examiner discussion questions, and the classic exam traps — the routine every FRACP, MRCP PACES, and ABIM candidate must perform flawlessly.
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- A patient with exophthalmos, chemosis, conjunctival injection and pain on eye movement may have active Graves orbitopathy with a risk of sight-threatening optic nerve compression — assess visual acuity, colour vision (red desaturation) and fields urgently, and check the Clinical Activity Score, because a CAS of three or more indicates active disease warranting urgent ophthalmology and endocrinology referral
- A patient with a rapidly enlarging, hard, fixed, irregular thyroid nodule with cervical lymphadenopathy has anaplastic or poorly differentiated thyroid carcinoma until proven otherwise — this is an urgent CT neck and fine-needle aspiration pathway, not a routine outpatient workup
- A thyrotoxic patient who develops fever, tachycardia above 140, atrial fibrillation, agitation, confusion or heart failure is in thyroid storm — this is a medical emergency requiring beta-blockade, thionamide, iodine, glucocorticoid and supportive care in a high-dependency setting
- A large goitre with stridor, dysphagia, facial plethora on arm elevation (Pemberton sign) or an inability to get below the gland indicates retrosternal extension with airway or great-vessel compression — image before any biopsy or surgery
Thyroid Status and Neck Examination — DCE Short-Case Routine
[1]The answer — nine steps, from behind the patient
The thyroid examination is the most-tested endocrine short case in the FRACP DCE and MRCP PACES, and it follows one invariant nine-step routine performed from behind the seated patient: general inspection, hands, pulse, eyes, neck inspection, neck palpation, percussion over the sternum, auscultation, then reflexes and legs. The instruction is almost always to examine the thyroid status — and that means two things in parallel: the status (hyperthyroid, euthyroid, hypothyroid) and the gland itself (size, consistency, nodularity, mobility, retrosternal extension). The candidate who palpates the neck and forgets the hands, eyes, reflexes and shins has examined the gland but not the status, and loses marks for the more important half of the assessment.[6]
References6ShowHide
- [1]Bartalena L, Baldeschi L, Boboridis K, et al. The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy Eur Thyroid J, 2016.PMID 27099835
- [2]Bartalena L, Kahaly GJ, Baldeschi L, Dayan CM, Eckstein A, et al. The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy Eur J Endocrinol, 2021.PMID 34297684
- [3]Bartalena L, Fatourechi V Extrathyroidal manifestations of Graves' disease: a 2014 update J Endocrinol Invest, 2014.PMID 24913238
- [4]Fatourechi V Pretibial myxedema: pathophysiology and treatment options Am J Clin Dermatol, 2005.PMID 16252929
- [5]Fatourechi V, Pajouhi M, Fransway AF Dermopathy of Graves disease (pretibial myxedema). Review of 150 cases Medicine (Baltimore), 1994.PMID 8309359
- [6]Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis Thyroid, 2016.PMID 27521067