MBBS OSCE · Endocrinology

OSCE — Graves disease and thyroid storm sequence

OSCE on diagnosing Graves disease, first-line carbimazole dosing, agranulocytosis counselling, beta-blockade, and correct pharmacological order in thyroid storm (thionamide before iodine).

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NEET-PGINICETUSMLEPLAB

Brief (to candidate)

A 34-year-old woman has weight loss, heat intolerance, AF, diffuse goitre with bruit, and proptosis. TSH suppressed, free T4 high. Later vignette: fever 39.8°C, confusion, rapid AF. 8 minutes.

Candidate instructions

  1. Diagnose Graves disease; list confirming tests (TRAb, uptake scan).
  2. Start carbimazole 20–30 mg daily + propranolol 20–40 mg q6–8h.
  3. Counsel agranulocytosis (sore throat/fever → stop drug, urgent FBC).
  4. Thyroid storm order: supportive (paracetamol not aspirin) → thionamide first → iodine ≥1 h later → beta-blocker → hydrocortisone 100 mg IV q8h.
  5. Mention RAI/surgery alternatives; pregnancy preferences (PTU first trimester often).

Examiner checklist

DomainExpected
DiagnosisGraves vs TMNG vs thyroiditis (orbitopathy pathognomonic)
Medical RxCarbimazole dose; 12–18 months titration course
SafetyAgranulocytosis warning; hepatotoxicity PTU
Storm orderThionamide before iodine (Wolff–Chaikoff after block)
AFRate control; anticoagulation decision per risk
SpecialPregnancy: avoid RAI; PTU early pregnancy nuances

Common errors

  • Giving iodine before thionamide.
  • Aspirin for cooling in storm.
  • Missing orbitopathy as Graves-specific.

Model key actions

  • Graves: TRAb + diffuse high uptake; orbitopathy is disease-specific.
  • Carbimazole 20 to 30 mg daily + propranolol; 12 to 18 month course; agranulocytosis warning mandatory.
  • Storm: cool, fluids, thionamide first, iodine after at least 1 h, beta-blockade, hydrocortisone 100 mg IV every 8 h; paracetamol not aspirin.
  • Pregnancy: no RAI; PTU often preferred early pregnancy then switch per local protocol.

Common errors

  • Iodine before thionamide in storm.
  • Offering RAI to pregnant patient.
  • Missing AF anticoagulation assessment.
References3Show
  1. [1]Davies TF, et al. Graves' disease. Nat Rev Dis Primers, 2020.PMID 32616746
  2. [2]Lee SY, Pearce EN Hyperthyroidism: A Review. JAMA, 2023.PMID 37847271
  3. [3]Ross DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism. Thyroid, 2016.PMID 27521067
OSCE — Graves disease and thyroid storm sequence · MBBS OSCE · NeetVellum