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Home / Complete thyroid examination
11-minute physical-examination master page

Complete thyroid examination

Perform a respectful thyroid examination, assess thyroid status and neck anatomy, identify suspicious nodules or compressive features, and state targeted biochemical and imaging investigations.

Candidate instructions

Thyroid swelling and palpitations — focused examination

Your task

Perform a focused thyroid examination on an adult with palpitations, weight loss and a neck swelling. At the end, summarize whether the patient appears hyperthyroid or hypothyroid, describe the thyroid gland and state your differential and investigations. You have 11 minutes.

Information available at entry
HR 112/min regularBP 138/76 mm HgRR 18/minSpO₂ 99%Temp 37.2°C
Safety priority: Severe tachycardia, fever, agitation/delirium, heart failure or hypotension in a patient with suspected thyrotoxicosis requires immediate assessment for thyroid storm and urgent treatment. Stridor or rapidly progressive compressive neck symptoms also require emergency escalation.

What examiners expect

  • Introduction, consent, hand hygiene and exposure of hands, face and neck.
  • General assessment for hyperthyroid/hypothyroid features.
  • Hands/pulse examination including tremor and rhythm.
  • Eye examination for thyroid eye disease when indicated.
  • Inspection of the neck at rest and during swallowing.
  • Systematic thyroid palpation including size, consistency, tenderness and nodules.
  • Cervical lymph-node assessment for suspicious nodules.
  • Targeted TSH/free T4 testing and ultrasound/FNA pathway when a nodule is present.
Timed rehearsal

Run the complete station in 11 minutes

Perform the patient-facing examination efficiently, then reserve the final 90–120 seconds for synthesis, differential, investigations, management and safety.

Review procedureOpen practice library
Station time
11:00

Ready for an 11-minute attempt.

Complete procedure

Exact 11-minute examination sequence

Use the sequence as a flexible performance framework. Patient safety and the task on the door always take priority over completing every maneuver.

0:00–0:35

1. Stability and thyroid emergency screen

Say: “Before the examination, I would review the pulse, temperature, blood pressure and mental status.”
  • Look for severe thyrotoxicosis, heart failure or airway compromise.
0:35–1:10

2. Introduce, identify and consent

Say: “I would like to examine your hands, eyes and neck, including feeling the thyroid gland. Is that okay?”
  • Hand hygiene.
  • Offer explanation before touching the neck.
1:10–2:15

3. General inspection, hands and pulse

Say: “Please hold your hands out.”
  • Warm/moist skin, tremor, palmar erythema.
  • Pulse rate and rhythm.
  • Nails and reflex changes when relevant.
2:15–3:10

4. Face and eyes

Say: “Please follow my finger with your eyes.”
  • Lid retraction/lag.
  • Proptosis, conjunctival irritation and extraocular movement restriction when Graves disease suspected.
3:10–4:00

5. Inspect the neck

Say: “I am looking at the front of your neck for swelling or asymmetry.”
  • Scars, diffuse enlargement, nodules and venous congestion.
4:00–4:40

6. Swallow test

Say: “Please take a sip of water and swallow when I ask.”
  • Observe upward movement of thyroid swelling.
  • Do not repeatedly provoke if swallowing is difficult.
4:40–6:30

7. Palpate thyroid from behind

Say: “I will stand behind you and gently feel the thyroid while you swallow.”
  • Identify cricoid and thyroid isthmus.
  • Palpate each lobe for size, consistency, tenderness and nodules.
  • Assess retrosternal extension indirectly; avoid aggressive manipulation.
6:30–7:20

8. Cervical lymph nodes

Say: “I will also feel for lymph nodes in your neck.”
  • Central and lateral cervical nodes when nodule/malignancy suspected.
7:20–8:00

9. Auscultation/special signs when indicated

Say: “If the gland is very vascular, I would listen for a bruit.”
  • Thyroid bruit in Graves disease.
  • Pemberton-type assessment only when large goitre/compression suspected and safe.
8:00–8:50

10. Completion examination

Say: “I would complete the examination with reflexes, proximal muscle power and cardiovascular assessment as indicated.”
  • Proximal myopathy.
  • Reflexes.
  • Heart failure/atrial fibrillation signs.
8:50–9:20

11. Comfort and hand hygiene

Say: “Thank you. I will help you get comfortable.”
  • Cover patient and clean hands.
9:20–11:00

12. Present and investigate

Say: “The patient appears clinically thyrotoxic with a diffusely enlarged smooth thyroid. I would confirm thyroid function biochemically and investigate the cause.”
  • TSH first with free T4/T3 as appropriate.
  • Thyroid antibodies when autoimmune disease suspected.
  • Ultrasound for structural thyroid/nodular assessment when indicated.
  • FNA based on ultrasound risk features and size thresholds, not simply because a nodule exists.
Interpretation

High-yield finding patterns

Finding patternClinical interpretation
Diffuse smooth goitre + tremor + eye signsGraves disease
Tender thyroid after viral illnessSubacute thyroiditis
Firm irregular nodule + cervical nodesPossible thyroid malignancy
Bradycardia, dry skin, delayed reflexesHypothyroidism
Tachyarrhythmia + weight loss + warm tremulous handsThyrotoxicosis
Clinical reasoning

Prioritized differential

  1. Graves disease
  2. Toxic multinodular goitre/toxic adenoma
  3. Thyroiditis
  4. Primary hypothyroidism with goitre
  5. Benign thyroid nodule/cyst
  6. Thyroid malignancy

Presentation formula

Start with stability, then the key positive and negative findings, localization or syndrome, leading diagnosis, and the most dangerous alternative that must be excluded.

Avoid: a long unranked list. Explain which finding makes each top diagnosis more or less likely.
Targeted tests

Investigations

Serum TSH with free T4 ± T3 according to result/clinical scenario

Thyroid receptor antibodies or other antibodies when autoimmune etiology is relevant

Ultrasound for structural thyroid disease/nodules

Fine-needle aspiration for nodules meeting sonographic/size criteria

ECG for significant palpitations/tachyarrhythmia and additional tests according to cause

Immediate plan

Management and disposition

  1. Treat severe thyrotoxicosis/thyroid storm as an emergency.
  2. For stable hyperthyroidism, control symptoms and establish etiology before definitive therapy.
  3. Use specialist/endocrine referral for significant thyrotoxicosis, pregnancy, large goitre, eye disease or complex nodules.
  4. Suspicious nodules require risk-stratified ultrasound/FNA and appropriate referral.
  5. Airway/compressive symptoms require urgent assessment.

Safety-netting

State exactly what would trigger urgent reassessment, specialist escalation, monitored care or admission. Do not hide emergency actions inside a generic “follow up” statement.

  • Checks for thyroid storm/airway red flags
  • Examines pulse and rhythm
  • Inspects and palpates gland systematically
  • Assesses eye signs when indicated
  • Checks cervical nodes with suspicious nodule
  • Orders TSH first-line appropriately
Self-assessment

Critical-action checklist

Use this after a timed attempt. These actions carry disproportionate safety value.

0 / 8 completed
0 / 8 critical actions completed
Evidence and next practice

References and linked learning

Reference starting points

Educational preparation only. Patient care must follow current patient-specific assessment, local policy and current guidelines.

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