Acquired hypothyroidism and Hashimoto thyroiditis — OSCE

Station brief (candidate)

• Explain Hashimoto thyroiditis in plain language: an autoimmune process in which the body's immune cells have gradually reduced the thyroid's output of hormone, which is why energy, weight, concentration and growth have changed. [1][4]
• Reassure that this is common, not caused by anything the family did, fully treatable, and that symptoms and school performance will recover with treatment. [3]
• Explain the treatment — a small daily tablet of levothyroxine, taken on an empty stomach before breakfast, and why timing and separation from iron, calcium, soy and antacids matter. [2][6]
• Outline the monitoring plan: blood test at six weeks to check the dose is right, then every four to six months, aiming to feel well with a normal thyroid level. [2]
• Address the young person directly: adherence, anchoring the tablet to a daily habit, and (age-appropriately) future pregnancy planning. [2]
• Mention screening for related conditions and the excellent long-term outlook. [3]

Role-player notes

You are a 13-year-old girl and your parent is with you. You are worried this is "for life," embarrassed about the weight gain, and anxious your school grades will not recover. You become withdrawn if the doctor talks only to your parent or uses jargon. You engage well when the doctor speaks to you directly, confirms the tiredness and brain fog are real and reversible, and gives a concrete, doable tablet routine. Your parent wants to know the cause and whether it runs in families. [4]

Expected candidate performance

1. Opening: "The blood tests show your thyroid gland has been working below its normal level. It is called Hashimoto thyroiditis. It is common, it is treatable, and the tiredness, weight change and difficulty concentrating you have noticed are exactly what we would expect — and they get better with treatment." [1]
2. Explanation of cause: An autoimmune process — the immune system, which usually fights infections, has been gently switching off the thyroid over months. It is not caused by diet, stress or anything the family did. It can run in families and is more common in adolescent girls. [1][4]
3. Treatment and adherence: A once-daily levothyroxine tablet, first thing in the morning on an empty stomach, 30 to 60 minutes before breakfast, kept separate from iron, calcium, soy and antacids. Offer a liquid if tablets are hard. Anchor it to a daily habit like waking or tooth-brushing. [2][6]
4. Monitoring and outlook: Blood test at six weeks to confirm the dose, then every four to six months. Aim to feel well with a normal thyroid level. Growth, energy, concentration and mood recover; cognition is preserved. A small possibility of coming off the tablet later in adolescence. [2][3]
5. Shared decision and safety-net: Agree the plan with the young person; flag that the dose will need review in pregnancy (it rises) and that they should return if symptoms recur or the tablet is missed regularly. [2]

Marking domains

• Clinical reasoning: correctly frames the diagnosis, classification and associated-condition screening. [1]
• Communication: speaks to the adolescent directly; plain language; addresses cause, reversibility and prognosis. [4]
• Treatment plan: weight-based levothyroxine, correct administration and monitoring target. [2]
• Shared decision-making and safety-netting: agrees a doable routine; flags pregnancy and symptom-recurrence review. [2]

Common fails

• Talking only to the parent and ignoring the adolescent. [4]
• Using jargon ("autoimmune thyroiditis", "TSH receptor") without translation. [3]
• Vague dosing ("a tablet") without the empty-stomach and separation guidance. [6]
• Failing to reassure that cognition is preserved and symptoms are reversible. [3]
• Omitting pregnancy counselling and the possibility of a future withdrawal trial. [2][5]