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Thyroid Status OSCE Examination Quiz
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A 29-year-old woman has signs of an overactive thyroid: a fine tremor, warm hands, lid lag and a diffuse goitre. Her pulse is irregularly irregular. You have thanked her, made her comfortable, washed your hands and summarised that she appears clinically hyperthyroid with possible Graves' disease. Which further action is most directly indicated to complete the examination?
- A Arrange an ECG to look for atrial fibrillation You picked ✓
- B Request thyroid autoantibodies as the only further investigation You picked ✕
- C Arrange a chest X-ray as the immediate priority to look for a retrosternal goitre You picked ✕
- D Arrange a neck ultrasound as the immediate priority because of the diffuse goitre You picked ✕
- E Arrange an urgent ophthalmology review because of the lid lag You picked ✕
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Incorrect
The answer is A: Arrange an ECG to look for atrial fibrillation
Explanation
Why A is correct
See Hands and Arms. Option A is correct. Completing an examination means linking what you found to the next step that matters most. This patient has the signs of thyrotoxicosis (the clinical state caused by too much thyroid hormone), and her pulse is irregularly irregular, which is the typical rhythm of atrial fibrillation (AF), a heart rhythm in which the atria quiver instead of contracting regularly. Thyrotoxicosis is an important and reversible cause of AF that should always be excluded, and AF is a recognised sign in hyperthyroidism. An irregular pulse is confirmed as AF by recording a 12-lead ECG (electrocardiogram), which changes how urgently she needs assessment and treatment. The other tests belong to the thyroid work-up, but they do not answer the question raised by the pulse. A plain-language aid: an irregularly irregular pulse in a thyrotoxic patient needs an ECG.
- Finding: An irregularly irregular pulse in a thyrotoxic patient.
- Likely rhythm: Atrial fibrillation, for which thyrotoxicosis is a reversible cause.
- Test: 12-lead ECG to confirm it.
Why the other options are incorrect
- B. Request thyroid autoantibodies as the only further investigation: Antibodies such as thyroid-stimulating hormone receptor antibodies help to confirm Graves' disease. They do not tell you anything about the rhythm, so they cannot be the only further step when the pulse is irregularly irregular. Your answer
- C. Arrange a chest X-ray as the immediate priority to look for a retrosternal goitre: A retrosternal goitre extends down behind the breastbone, and it is looked for at the bedside by percussion and by Pemberton's test. A chest X-ray does not assess the pulse, so it does not address the finding that most needs a next step. Your answer
- D. Arrange a neck ultrasound as the immediate priority because of the diffuse goitre: An ultrasound of the neck may help to characterise a goitre or nodules, but it does not address the irregular pulse. It is not the most urgent step for a woman who may have an abnormal heart rhythm. Your answer
- E. Arrange an urgent ophthalmology review because of the lid lag: Lid lag is a sign of sympathetic overactivity of the muscle that lifts the upper lid, and it is not itself thyroid eye disease. Ophthalmology review is for significant eye disease, such as marked proptosis or double vision, which this woman does not have. Your answer
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More questions from this set. Start the quiz to answer them and see each explanation.
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1
A young woman with features of an overactive thyroid has both eyes bulging forward and reports double vision when looking to the side. Which mechanism best explains these eye findings?
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2
At the start of a thyroid examination, you observe a patient from the end of the bed. She is restless and fidgety, is dressed lightly despite a cool room and reports recent weight loss despite a good appetite. Which mechanism best explains these findings?
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