📋 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · GOITER

Goiter · Short Case

Candidate task: perform focused examination on a child with goiter, discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ · Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: sitting for thyroid exam, then supine for GPE.
👕 Exposure — neck and chest fully exposed.
➡️ Approach from the right side (palpate thyroid from behind).
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations:

  • Body habitus: short stature (hypothyroidism), tall (hyperthyroidism).
  • Nutritional status: overweight (hypothyroidism), underweight (hyperthyroidism).
  • Skin: dry, coarse (hypothyroidism); warm, moist (hyperthyroidism).
  • Eyes: exophthalmos, lid retraction, lid lag (Graves' disease).
  • Tremor: fine tremor of outstretched hands (hyperthyroidism).
  • Voice: hoarseness (hypothyroidism, or if goiter compresses recurrent laryngeal nerve).
👁 Red flags: goiter + exophthalmos + tachycardia → Graves' disease. Goiter + hypothyroid features → Hashimoto's thyroiditis.
03 Thyroid Examination (Inspection, Palpation, Auscultation) ▾

Systematic thyroid exam:

  • Inspection: visible swelling, symmetry, skin changes (erythema – thyroiditis), distended veins (retrosternal extension).
  • Palpation (from behind): size, shape, consistency (firm – Hashimoto's, soft – Graves', nodular – multinodular goiter / malignancy), tenderness (thyroiditis).
  • Mobility: ask child to swallow (thyroid moves with swallowing).
  • Auscultation: bruit (hyperthyroidism – increased vascularity).
  • Check for retrosternal extension: percussion over manubrium, Pemberton's sign.
  • Lymph nodes: cervical lymphadenopathy (malignancy).
📌 Examiner expectation: demonstrate technique – stand behind the child, use both hands to palpate. Describe findings systematically.
04 General Physical Exam (Hands → Face → CVS → Limbs) ▾

Systematic examination:

  • Hands: tremor (hyperthyroidism), dry skin (hypothyroidism), thyroid acropachy (Graves').
  • Face: myxoedema (hypothyroidism), exophthalmos (Graves'), moon face (hypothyroidism).
  • Eyes: lid retraction, lid lag, exophthalmos, ophthalmoplegia (Graves' ophthalmopathy).
  • Cardiovascular: tachycardia / atrial fibrillation (hyperthyroidism), bradycardia (hypothyroidism), hypertension (hyperthyroidism).
  • Neurological: brisk reflexes (hyperthyroidism), delayed relaxation (hypothyroidism).
  • Skin: pretibial myxoedema (Graves'), vitiligo (autoimmune association).
  • Growth: height, weight, BMI.
🔍 Key associations: goiter + hyperthyroid features → Graves' disease. Goiter + hypothyroid features → Hashimoto's thyroiditis. Goiter + painful thyroid → subacute / suppurative thyroiditis.
05 Developmental Assessment & Associated Signs ▾

Assess:

  • Motor milestones: may be delayed (hypothyroidism – if congenital).
  • Cognitive function: school performance (hypothyroidism can cause learning difficulties).
  • Behaviour: anxiety, hyperactivity (hyperthyroidism); lethargy, depression (hypothyroidism).
  • Associated autoimmune conditions: type 1 diabetes, Addison's, vitiligo, coeliac disease.
  • Family history: autoimmune thyroid disease, goiter.
🧠 Genetic clues: goiter + congenital hearing loss → Pendred syndrome. Goiter + hypothyroidism + family history → Hashimoto's thyroiditis.

📋 Case Presentation – (fill in during exam)

This is a _____-year-old _____ child, referred for _____ (neck swelling / goiter). On examination, the child appears _____ (hyper/hypothyroid features). Thyroid exam: swelling _____ (size, symmetry, consistency, tenderness), moves with swallowing _____, bruit _____. General exam: _____ (hands, eyes, CVS, neurological). Developmental: _____ (appropriate/delayed). Associated signs: _____.

2. Viva Discussion (≈4 min)
06 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

Diffuse Goiter
• Graves' disease (hyperthyroid)
• Hashimoto's thyroiditis (euthyroid or hypothyroid)
• Simple (colloid) goiter (euthyroid)
• Iodine deficiency goiter (endemic)
• Subacute thyroiditis (painful)
• Drug‑induced (lithium, amiodarone)
Nodular Goiter
• Multinodular goiter (benign)
• Thyroid adenoma (toxic / non‑toxic)
• Thyroid carcinoma (papillary, follicular, medullary)
Other
• Thyroglossal cyst (midline, moves with tongue)
• Lymphadenopathy
• Dermoid cyst
• Branchial cleft cyst

🔹 Investigations – Diagnosis

• Thyroid function tests – TSH, free T4, free T3.
• Thyroid autoantibodies – anti‑TPO, anti‑TG (Hashimoto's), TRAb (Graves').
• Thyroid ultrasound – size, nodularity, vascularity, suspicious features.
• Fine‑needle aspiration (FNA) – if nodule >1 cm with suspicious features.
• Radioiodine uptake scan – if hyperthyroid, differentiate Graves' vs toxic nodule.

🔹 Investigations – Aetiology

• Genetic testing – if congenital hypothyroidism (PAX8, FOXE1, TSHR).
• Urinary iodine – if iodine deficiency suspected.
• Thyroglobulin – marker for thyroid tissue (e.g., in congenital hypothyroidism).
• Calcitonin – if medullary thyroid carcinoma suspected (MEN2).

🔹 Investigations – Exclude Others

• Ultrasound – exclude thyroid nodules / malignancy.
• FNA – if suspicious nodule.
• Chest X‑ray / CT – if retrosternal extension.
• Laryngoscopy – if hoarseness (recurrent laryngeal nerve involvement).

🔹 Investigations – Rule Out Complications

• Thyroid function – monitor for hypo/hyperthyroidism.
• Ultrasound – monitor nodule size.
• Ophthalmology – if Graves' ophthalmopathy.
• Cardiac – if hyperthyroidism (tachyarrhythmia).

🔹 Management – Across Organ Systems

Graves' Disease

Antithyroid drugs (carbimazole, methimazole), beta‑blockers (symptomatic). Radioiodine (if older) or surgery (if failed medical / large goiter).

Hashimoto's Thyroiditis

Thyroxine replacement if hypothyroid. Monitor thyroid function.

Simple Goiter

Reassurance; monitor TSH. Thyroxine if TSH elevated.

Toxic Nodule

Radioiodine or surgery.

Malignancy

Total thyroidectomy + radioiodine (if papillary/follicular). Medullary – thyroidectomy + lymph node dissection.

Congenital Hypothyroidism

Thyroxine replacement (start as soon as possible).

Subacute Thyroiditis

NSAIDs, corticosteroids (if severe).

Surveillance

Monitor thyroid function, ultrasound (if nodules).

📈 Prognosis

  • Graves': remission possible with medical therapy; relapse common. Radioiodine/surgery → lifelong thyroxine.
  • Hashimoto's: lifelong thyroxine; otherwise good prognosis.
  • Simple goiter: excellent; may resolve.
  • Papillary thyroid cancer: excellent prognosis in children (near 100% survival).
  • Medullary thyroid cancer: depends on stage; genetic screening (MEN2) important.

📋 Follow‑up Schedule

  • Graves': endocrinology 3‑6 monthly; monitor TFTs.
  • Hashimoto's: endocrinology 6‑12 monthly; TFTs.
  • Thyroid cancer: endocrinology 3‑6 monthly; thyroglobulin, ultrasound.
  • Congenital hypothyroidism: endocrinology 1‑3 monthly in infancy; then 3‑6 monthly.
  • All: transition to adult endocrinology.
💡 Examiner expectation: systematic examination of the thyroid gland (inspection, palpation, auscultation). Know the causes of goiter and approach to investigation. Be able to differentiate hyperthyroid, hypothyroid, and euthyroid goiter.
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Mock OSCE · Goiter · Based on Wyne‑Harris, Nelson & Pediatric Clinical Advisor