MBBS OSCE · Endocrinology / General Medicine

OSCE — assessment and management of suspected hypothyroidism

An 8-minute OSCE station assessing the candidate's structured assessment, TFT interpretation, and management of a patient with suspected hypothyroidism, with escalation to the myxoedema-coma bundle when the scenario decompensates. Marks for dosing and the cortisol-first principle.

8 min stationVerification in progress
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NEET-PGINICETUSMLEPLAB

Brief (to candidate)

A 72-year-old woman with known hypothyroidism is brought in drowsy. She stopped her levothyroxine two months ago and has had a chest infection for a week. Core temperature 32.5 degrees C, heart rate 42, respiratory rate 10, SpO2 91 percent on air, sodium 121 mmol/L. You have 8 minutes to assess her, establish the diagnosis, and outline immediate and definitive management.

Candidate instructions

  1. Take a focused, structured history and examine using an ABCDE approach.
  2. Establish the diagnosis using the thyroid function tests provided and recognise the severity.
  3. Outline the immediate management, including drug therapy with doses, route and rationale.
  4. State your definitive plan (oral replacement, monitoring) and your disposition (ward vs ICU).

Examiner checklist (mark each domain / 10)

DomainKey actions expected
ABCDE / resuscitationAirway; oxygen and ventilatory support for hypoventilation/hypercapnia; IV access; identify the precipitant (infection, missed doses)
Diagnosis & severityRecognises myxoedema coma (hypothermia + bradycardia/hypoventilation + reduced consciousness + hyponatraemia) on a background of overt primary hypothyroidism (high TSH + low free T4)[2]
Emergency pharmacologyIV levothyroxine loading 200-500 mcg, then 50-100 mcg/day; IV hydrocortisone 100 mg with or before thyroid hormone (send cortisol first); states cortisol-first rationale[7]
Supportive carePassive rewarming (not active); cautious hyponatraemia correction; treat the chest infection with antibiotics; avoid sedatives
InvestigationsTSH and free T4; cortisol/Synacthen before thyroid hormone; FBC, U&E, CK, lipids, glucose, cultures, CXR
Definitive planConvert to oral levothyroxine ~1.6 mcg/kg/day (lower maintenance in elderly); recheck TSH at 6-8 weeks; lifelong replacement with TSH every 6-12 months; anti-TPO; education on fasting dosing[3]
Differential & safety-netConsiders sepsis, adrenal crisis, hypoglycaemia, drug overdose in the comatose hypothermic patient; ICU disposition

Model key actions

  • Oxygen and ventilatory support for hypoventilation; identify and treat the chest infection.[7]
  • IV levothyroxine 200-500 mcg loading then 50-100 mcg/day + IV hydrocortisone 100 mg, with cortisol checked first and passive rewarming.[7]
  • Recognise that a normal TSH with low free T4 would indicate central disease and mandate cortisol before thyroid hormone and pituitary imaging.[2]
  • On recovery, oral levothyroxine titrated to TSH (recheck 6-8 weeks); lifelong; reinforce adherence and fasting dosing.[3]

Common errors

  • Treating myxoedema coma with oral levothyroxine (unreliable absorption).
  • Withholding hydrocortisone pending the cortisol result, risking adrenal crisis.
  • Active external rewarming, which can precipitate cardiovascular collapse.
  • Missing the precipitant (infection, sedatives, missed doses).
  • Failing to distinguish primary from central disease (low/normal TSH + low free T4), and therefore failing to give cortisol first.
References3Show
  1. [2]Taylor PN, et al. Hypothyroidism. Lancet, 2024.PMID 39368843
  2. [3]Jonklaas J, et al. Guidelines for the treatment of hypothyroidism (ATA/AACE). Thyroid, 2014.PMID 25266247
  3. [7]Kruithoff ML, Gigliotti BJ. Thyroid Emergencies: A Narrative Review. Endocrine Practice, 2025.PMID 40553957
OSCE — assessment and management of suspected hypothyroidism · MBBS OSCE · NeetVellum