MBBS OSCE · Endocrinology / General Medicine

OSCE — assessment and management of a painful thyroid and thyrotoxicosis

An 8-minute OSCE station assessing the candidate's structured neck/thyroid assessment, TFT and radioactive-iodine-uptake interpretation, and phase-specific management of subacute (De Quervain) thyroiditis, with the key differentiation from Graves disease. Marks for the low-vs-high RAIU rule and the no-antithyroid-drug principle.

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NEET-PGINICETUSMLEPLAB

Brief (to candidate)

A 32-year-old woman presents with a 10-day history of fever, malaise and a painful anterior neck that radiates to her jaw, worse on swallowing, following a sore throat two weeks ago. She has palpitations and sweating. On examination she is febrile with a tender, firm thyroid. You have 8 minutes to assess her, establish the diagnosis, interpret the investigations provided, and outline the management.

Candidate instructions

  1. Take a focused, structured history (pain character, radiation, preceding viral illness, thyroid/autoimmune history, drugs) and examine the neck and thyroid with attention to tenderness, consistency and eye signs.
  2. Interpret the thyroid function tests, ESR/CRP and the radioactive iodine uptake provided.
  3. Establish the diagnosis and the phase of the illness, and differentiate it from Graves disease.
  4. Outline the management with drug, dose, route and rationale, and the follow-up plan.

Examiner checklist (mark each domain / 10)

DomainKey actions expected
History & examinationElicits painful tender thyroid radiating to jaw, fever, preceding viral upper respiratory infection; confirms tenderness and a firm gland; checks for eye signs (to exclude Graves) and compressive features
Diagnosis & phaseDiagnoses subacute (De Quervain) thyroiditis in the thyrotoxic phase (suppressed TSH + raised free T4) and states it is self-limiting[1]
Investigation interpretationInterprets low radioactive iodine uptake (leak, not synthesis) vs high diffuse in Graves; markedly raised ESR/CRP; anti-TPO variable; states the low-vs-high RAIU discriminator[1][2]
DifferentiationExplicitly contrasts with Graves (painless diffuse goitre, eye signs, TRAb positive, high diffuse uptake) and painless thyroiditis (non-tender, normal ESR)[2]
ManagementNSAIDs first-line; oral prednisolone 40 mg daily tapered 2-4 weeks if severe; beta-blocker (propranolol) for the thyrotoxic phase; states antithyroid drugs are NOT used (hormone leaking, not synthesised); levothyroxine only if hypothyroid phase is symptomatic[1]
Follow-up & safety-netMonitor TFTs to recovery; warn of a later hypothyroid phase; biopsy any dominant/rapidly enlarging nodule (exclude malignancy/lymphoma)[3]
DifferentialConsiders acute suppurative thyroiditis (abscess, very unwell, drainage) and haemorrhage into a nodule as causes of a painful thyroid

Model key actions

  • Recognise the painful tender thyroid + high ESR + low RAIU triad as subacute (De Quervain) thyroiditis, post-viral and self-limiting.[1]
  • State that the thyrotoxic phase is treated with a beta-blocker, NOT antithyroid drugs, because the hormone is leaking from a damaged gland; add NSAIDs, or prednisolone 40 mg if severe.[1]
  • Use RAIU to separate thyroiditis (low) from Graves (high); check TRAb (negative in thyroiditis) and eye signs (absent in thyroiditis).[2]
  • Counsel the patient on the self-limiting course and a possible hypothyroid phase, with TSH monitoring.[1]

Common errors

  • Treating the thyrotoxic phase with carbimazole/PTU or radioiodine — ineffective; the gland is leaking, not synthesising.
  • Missing the diagnosis by not eliciting tenderness or not checking the ESR/CRP.
  • Mislabelling as Graves because TSH is suppressed — Graves has eye signs, a painless goitre, TRAb positivity and high uptake.
  • Failing to consider acute suppurative thyroiditis in a very unwell patient with a fluctuant swelling (needs antibiotics and drainage).
  • Not counselling on the biphasic course and possible hypothyroid phase.
References3Show
  1. [1]Wiersinga WM, et al. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes and Endocrinology, 2023.PMID 36848916
  2. [2]Ross DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid, 2016.PMID 27521067
  3. [3]Ralli M, et al. Hashimoto's thyroiditis: an update on pathogenic mechanisms, diagnostic protocols, therapeutic strategies, and potential malignant transformation. Autoimmunity Reviews, 2020.PMID 32805423
OSCE — assessment and management of a painful thyroid and thyrotoxicosis · MBBS OSCE · NeetVellum