Thyroid Examination
An 11-step thyroid examination assessing thyroid status, the eyes and the neck, including comments on findings.
Endocrinology · Self-paced
11 sections · 53 actionable steps
Before you begin
Equipment
Glass of water
Sheet of paper for tremor
Stethoscope
Tendon hammer
Watch with a second hand
The aim
Decide the patient’s thyroid status, then describe the gland.
The hands, pulse and face tell you if the patient is hyper-, hypo- or euthyroid. The eyes and neck point to the cause.
How to use this guide
Read it through: Learn the sequence and the reason behind each step before you practise.
Practise in pairs: One examines, one reads the steps aloud and ticks each circle as it is completed.
Present aloud: Finish every attempt with a concise summary, as you would for an examiner.
The sequence
Talk
Introduce, consent, position
Status
General, hands, pulse, face
Eyes
Inspect, lid lag, movements
Neck
Inspect, swallow, palpate
Close
Percuss, bruit, legs
Step 1. Introduction
Hand hygiene
Hand wash/rub
Introduce yourself
Explain the purpose
Obtain consent
Ask about pain
Ask about any pain or tenderness in the neck before you touch it
Position and exposure
Sit the patient upright on a chair with room to stand behind them. Expose the neck down to the clavicles
Glass of water
Have a glass of water ready for the swallow test
Set up first
Use a chair away from the wall so you can stand behind the patient. Pour the water before you begin.
Status first, gland second
Every finding from the hands to the face answers one question: is this patient hyper-, hypo- or euthyroid?
Step 2. General Inspection
Body habitus
Weight loss or weight gain
Demeanour
Anxious, restless and fidgety, or slow and lethargic
Dress for the temperature
Under-dressed and sweaty (heat intolerance) or wrapped up warmly (cold intolerance)
Voice
Hoarse or slow speech
Surroundings
Look for medications, a fan or extra blankets around the patient
Step 3. The Hands
Temperature and sweating
Warm and moist palms, or cool and dry skin
Palmar erythema
Reddening of the thenar and hypothenar eminences
Onycholysis
Separation of the nail from the nail bed (Plummer’s nails)
Thyroid acropachy
Clubbing-like finger swelling with periosteal new bone, seen in Graves’ disease
Fine tremor
Arms outstretched, fingers spread. Lay a sheet of paper over the hands to exaggerate the tremor
Graves’ in the hands
Thyroid acropachy is specific to Graves’ disease. Tremor, sweating and onycholysis occur in any cause of thyrotoxicosis.
Step 4. The Pulse and Arms
Radial pulse
Rate and rhythm over at least 30 seconds: tachycardia or atrial fibrillation, or bradycardia
Proximal myopathy
Arms abducted to 90°, ask the patient to resist as you push down on the upper arms
Biceps reflex
Brisk in hyperthyroidism; slow to relax in hypothyroidism
Blood pressure — comment only
Comment only — do not performWide pulse pressure in hyperthyroidism; diastolic hypertension in hypothyroidism
Always check the rhythm
Atrial fibrillation is a common complication of thyrotoxicosis, especially in older patients.
Step 5. The Face
Skin
Dry, coarse or pale skin; a malar flush
Hair
Diffuse thinning, or dry and coarse hair
Eyebrows
Loss of the outer third of the eyebrows
Periorbital puffiness
Seen in hypothyroidism
Tongue
Macroglossia in severe hypothyroidism
Step 6. The Eyes
Inspect from the front
Lid retraction: sclera visible above the iris. Conjunctival injection and chemosis
Inspect from the side and above
Stand behind the patient and look down over the forehead for exophthalmos (proptosis)
Lid lag
Ask the patient to follow your finger from above eye level down to the floor. Look for sclera above the iris as the eye moves down
Eye movements
Test in an H pattern, keeping the head still. Ask about double vision or pain on movement
Lid lag or exophthalmos?
Lid retraction and lid lag occur in any thyrotoxicosis. Exophthalmos, chemosis and ophthalmoplegia point to Graves’ disease.
Move slowly
Move your finger slowly during the lid lag test and hold it about 50 cm from the face.
Examiner note
Offer visual acuity, colour vision and fundoscopy if there are features of Graves’ eye disease.
Step 7. Inspection of the Neck
Inspect from the front
Midline or lateral swelling, scars (a collar incision from thyroidectomy), skin changes and distended veins
Inspect from the side
Look at the profile of the neck for a subtle goitre
Swallow test
Sip of water, hold it in the mouth, then swallow. A thyroid swelling rises with swallowing
Tongue protrusion
Ask the patient to stick out their tongue. A thyroglossal cyst rises with tongue protrusion
Why it moves
The thyroid sits inside the pretracheal fascia, so it rises on swallowing. A thyroglossal cyst is tethered to the tongue.
Describe a lump
Site, size, shape, surface, consistency, tenderness, mobility, and whether you can get below it.
Step 8. Palpation of the Neck
Warn the patient
Explain that you will stand behind them and feel the neck
Find the isthmus
Neck slightly flexed. Palpate in the midline from the cricoid cartilage down to the sternal notch
Palpate each lobe
Size, shape, consistency, tenderness, nodules and mobility. Retract the sternocleidomastoid to feel each lobe
Palpate while swallowing
Ask the patient to swallow again and feel the gland rise; try to get below it
Palpate with tongue protrusion
For a midline lump, feel whether it rises as the tongue is protruded
Cervical lymph nodes
Submental, submandibular, pre- and post-auricular, occipital, cervical chains and supraclavicular nodes
Trachea
From the front, check that the trachea is central
Stand behind
Keep the neck slightly flexed to relax the strap muscles. Use the pads of both hands and keep watching the patient’s face for pain.
Step 9. Percussion and Auscultation
Percuss the manubrium
Dullness over the upper sternum suggests retrosternal extension of a goitre
Auscultate each lobe
Listen with the diaphragm for a thyroid bruit; ask the patient to hold their breath
Pemberton’s sign
Ask the patient to raise both arms above the head for one minute. Facial plethora, distended neck veins or stridor suggest thoracic inlet obstruction
Bruit or murmur?
A thyroid bruit suggests the increased blood flow of Graves’ disease. Listen over the aortic area to exclude a radiating murmur.
Step 10. The Lower Limbs
Pretibial myxoedema
Raised, firm, pink-brown plaques over the shins, seen in Graves’ disease
Peripheral oedema
Non-pitting oedema in hypothyroidism
Proximal myopathy
Ask the patient to stand from the chair with their arms crossed
Ankle reflexes
Brisk in hyperthyroidism; slow-relaxing in hypothyroidism. Test with the patient kneeling on a chair if needed
Hung-up reflexes
A slow relaxation phase after the ankle jerk is a classic sign of hypothyroidism.
Step 11. Conclusion
Thank the patient
Thank the patient and help them to cover up
Hand hygiene
Hand wash/rub
State the thyroid status
Clinically hyperthyroid, hypothyroid or euthyroid
Describe the neck
Diffuse goitre, multinodular goitre, solitary nodule or no palpable abnormality
Suggest further investigations
Thyroid function tests, thyroid antibodies, ultrasound of the neck and fine-needle aspiration if a nodule is found
Finish strongly
Give the thyroid status first, then the neck findings and eye signs, then your likely diagnosis and investigations.
Run it from memory
Cover the steps and recite the sequence.
- Step 1. Introduction
- Step 2. General Inspection
- Step 3. The Hands
- Step 4. The Pulse and Arms
- Step 5. The Face
- Step 6. The Eyes
- Step 7. Inspection of the Neck
- Step 8. Palpation of the Neck
- Step 9. Percussion and Auscultation
- Step 10. The Lower Limbs
- Step 11. Conclusion
What your findings mean
Thyroid status at a glance
Check each finding against both columns.
| Feature | Hyperthyroidism | Hypothyroidism |
|---|---|---|
| General | Weight loss, anxious, restless, heat intolerant | Weight gain, slow, lethargic, cold intolerant |
| Hands | Warm and sweaty, fine tremor, onycholysis, palmar erythema | Cool and dry, carpal tunnel signs |
| Pulse | Tachycardia, atrial fibrillation, wide pulse pressure | Bradycardia, diastolic hypertension |
| Face and hair | Diffuse hair thinning | Dry coarse hair, loss of outer third of eyebrows, periorbital puffiness, hoarse voice |
| Eyes | Lid retraction and lid lag | Periorbital oedema |
| Muscles and reflexes | Proximal myopathy, brisk reflexes | Proximal myopathy, slow-relaxing reflexes, non-pitting oedema |
Types of goitre
| Type | Possible causes or description |
|---|---|
| Diffuse, smooth | Graves’ disease, Hashimoto’s thyroiditis, iodine deficiency, puberty and pregnancy |
| Multinodular | Toxic or non-toxic multinodular goitre |
| Solitary nodule | Cyst, adenoma, carcinoma, or a dominant nodule within a multinodular goitre |
| Tender | Subacute (de Quervain’s) thyroiditis, or bleeding into a cyst |
Signs of Graves’ disease
| Area | Signs |
|---|---|
| Eyes | Exophthalmos, chemosis, ophthalmoplegia |
| Skin | Pretibial myxoedema |
| Hands | Thyroid acropachy |
| Neck | Diffuse smooth goitre with a bruit |
Midline neck lump
| Moves with | Likely cause |
|---|---|
| Swallowing only | Thyroid |
| Swallowing and tongue protrusion | Thyroglossal cyst |
| Neither | Lymph node, dermoid or lipoma |
Act on these findings
Stridor or a positive Pemberton’s sign — possible airway compression; urgent review.
Reduced vision or colour vision in Graves’ eye disease — possible optic nerve compression; emergency ophthalmology.
Fever, tachycardia, agitation or confusion in thyrotoxicosis — consider thyroid storm.
Hard, fixed nodule, nodes or a hoarse voice — suspect malignancy; urgent ultrasound and FNA.
Presenting your findings
Model presentation
“I examined Ms Patel, a 34-year-old woman, who appeared slim, anxious and restless. Her palms were warm and sweaty, with a fine tremor and onycholysis. Her pulse was 112 and irregularly irregular. She had bilateral exophthalmos with lid retraction and lid lag, and full eye movements without diplopia.
There was a diffuse, smooth, non-tender goitre that rose with swallowing but not with tongue protrusion, with a bruit over both lobes. There was no retrosternal dullness or lymphadenopathy, and Pemberton’s sign was negative. Reflexes were brisk. She is clinically hyperthyroid, and these findings are consistent with Graves’ disease complicated by atrial fibrillation.”
Structure
| Step | Include |
|---|---|
| 01 · Who | Name, age, setting |
| 02 · Status | Hyper-, hypo- or euthyroid |
| 03 · Eyes | Thyrotoxic or Graves’ signs |
| 04 · Neck | Type of goitre, nodes, airway |
| 05 · Conclude | Diagnosis and next steps |
Common pitfalls
Not stating the thyroid status
Palpating from the front only
Standing behind without warning the patient
Forgetting the tongue protrusion test
Skipping retrosternal percussion and Pemberton’s sign
Calling lid lag exophthalmos
To complete the examination
Thyroid function tests: TSH, free T4 and T3
Thyroid antibodies: TRAb, anti-TPO
Ultrasound of the neck, with FNA for nodules
Radioisotope uptake scan if thyrotoxic
ECG if the pulse is irregular
Ophthalmology review if eye signs are present
Sources
Checklist steps: written in the med study partner examination checklist format.
Further reading: Talley NJ, O'Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis. Elsevier. Macleod’s Clinical Examination. Elsevier.
Always follow your own medical school's marking criteria and local clinical policies.
Educational use only
Made for learning, not for clinical decision-making.
Educational only. Not medical advice or a substitute for supervised clinical training.
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