Endocrine and thyroid examination and how to present it

• The endocrine and thyroid examination is a focused, systematic inspection and palpation of the whole patient, not only of the neck; the thyroid is examined from behind with the neck swallowing and with the tongue protruded so that a thyroglossal cyst can be distinguished from a goitre. ^[7]
• The hands, eyes, pulse, tremor and reflexes tell you the patient's thyroid status (euthyroid, hypothyroid or hyperthyroid) before you touch the neck, and the neck and its lymph nodes tell you why.
• A solitary palpable thyroid nodule is generally over about 1 cm in size; nodules and cervical nodes are described objectively, by site, size, consistency, mobility and temperature, never by a single word. ^[1]
• The same knowledge is used to spot two masqueraders of endocrine disease that commonly accompany thyroid disease: Cushingoid and acromegalic appearance, and the eye, foot and fundus signs of diabetes.
• A good endocrine presentation names the single most important finding first, groups the normal systems, states the important negatives, gives numbers, and ends with a one-line impression, the main alternative and a plan.

By the end of this page you should be able to:

1. Prepare the patient, yourself and the setting for a neck, endocrine and diabetes examination.
2. Perform the examination in a fixed, logical order and say what you are looking for at each step.
3. Recognise the common thyroid signs and state what they mean, including thyroid eye disease, pretibial myxoedema and the hands-and-eyes of thyroid disease.
4. Describe a goitre and a thyroid nodule objectively, and auscultate for a thyroid bruit safely.
5. Recognise the appearance of Cushing syndrome, acromegaly and Addison disease, and describe the diabetic foot, injection site and fundus examination.
6. Turn a raw list of findings into a bedside presentation of a normal neck, Graves disease or multinodular goitre, in spoken and written form.

This page is the examination and presentation guide for endocrine and thyroid disease. It assumes you already know the diseases in principle; what it teaches is the bedside craft of eliciting and reporting their signs. It is written for a medical student meeting the examination for the first time, and the standard it is held to is that of a safe, unaided encounter at the bedside, followed by a presentation a senior can act on.

What the examination is for. It has three separate jobs, and keeping them separate is the first skill. First, it decides thyroid status: euthyroid (clinically normal thyroid function), hypothyroid (underactive thyroid) or hyperthyroid (overactive thyroid). Second, it decides thyroid aetiology: for example Graves disease, Hashimoto thyroiditis, a toxic nodule or multinodular goitre. Third, in a patient with type 1 or type 2 diabetes mellitus or possible hypercortisolism or acromegaly, it looks for complications and for associated endocrine disease. A euthyroid gland in a patient with unchanged pulses, weight, skin and eyes tells you as much as a diseased gland, and must be said aloud.

The setting. Work in a warm, well-lit room with a chair and a couch or bed that can be raised. The patient sits on the edge of the bed with the neck relaxed and slightly flexed for palpation, then stands for inspection of the neck and gait, and lies flat for the fundus examination. Have good light, a glass of water, a pen-torch, a stethoscope bell, a 128 Hz tuning fork, a cotton-wool wisp, a disposable ophthalmoscope, a tape measure and a small ruler. Ask about neck pain before you begin, because thyroiditis can be tender.

Preparation is performed once and in the same order every time. A good presentation cannot be rescued if its facts were gathered without respect for the patient, and facts are only worth gathering when the patient is settled.

• Introduction. Knock, greet the patient, state your name and role, and ask how they wish to be addressed. Explain briefly what you are about to do and that they can stop at any time. Most adults understand "I am going to feel the front of your neck while you drink some water" without more.
• Consent. For a routine neck and thyroid examination, consent is usually implied by cooperation. For any intimate, painful or potentially sensitive component, including fundoscopy in a vulnerable patient, or for examination of the feet and injection sites that requires undressing, obtain explicit consent. Stop immediately if consent is withdrawn.
• Chaperone. Offer a trained chaperone when you examine the neck in a private setting with a single examiner, and for any component of the examination that is intimate or that exposes the body. Record the offer and the response in the notes.
• Hand hygiene. Clean your hands before and after patient contact, before any clean or aseptic procedure, and after exposure to body fluids, in accordance with current World Health Organization guidance on hand hygiene in health care. ^[8] If you present at the bedside, re-clean between patients and avoid contaminating the stethoscope and pen-torch.
• Exposure and position. Expose the neck from the clavicles to the mandible and the hands, eyes, feet and any injection sites to be examined; drape for modesty and warmth. Ask the patient to remove necklaces, scarves and high collars. Ask them to stand with the neck slightly extended for inspection, then sit and flex slightly for palpation, then stand again for retrosternal goitre assessment.
• Position of the examiner. Stand or sit behind and slightly to the patient's right for thyroid palpation, so that your hands, the patient's neck and the light work together; then return to face the patient for inspection and the presentation.
• Materials and records. Have the drug sheet, observations and prior letters to hand before you begin, so that you do not interrupt the presentation to search. If an observation changes while you wait, re-check it before you speak.

The order below is the one used at the bedside in a complete endocrine encounter. Perform it in exactly this order and you will not forget a step; you can later compress or regroup once it is automatic. At each step, state what is normal and abnormal, because the patient is learning from you as much as your senior is.

1. Introduce, consent and expose. As above. Tell the patient you are going to look at the whole body briefly, because thyroid disease affects the hands, eyes and heart as well as the neck.
2. General inspection. Look at the patient before they speak. Note build (cachectic, obese or unchanged), skin colour, voice (hoarse or unchanged), breathlessness at rest, visible tremor and whether they look uncomfortable. Watch the neck at rest for a goitre without drawing attention to it yet.
3. Hands and arms. Ask the patient to hold both hands out with the fingers slightly spread and the wrists extended for about 30 seconds. Look for a fine tremor, warm moist palms, palmar erythema, proximal myopathy (inability to keep the arms up against gravity), and acromegalic change (spade-like fingers, thickened soft tissues, prominence of the heel pads). Turn the hands over for the nails and for skin pigmentation. Ask about grip strength and wrist pain, because carpal tunnel syndrome is common in acromegaly.
4. Pulse and blood pressure. Count the pulse at the radial artery for a full minute, by auscultation over the apex if it is irregularly irregular, and state the rate and rhythm. Look for radio-femoral delay by palpating the radial and femoral pulses together. Measure blood pressure sitting, and again after standing for one minute, looking for a fall that does not recover. Record all numbers with units.
5. Eyes and eyelids. Inspect from the front and from the side for proptosis (forward displacement of the globe), upper lid retraction with sclera visible above the iris, lid lag on downgaze (the sclera still visible when the patient looks down), chemosis (conjunctival oedema), eyelid oedema, conjunctival injection, grittiness and watering. Ask the patient to follow your finger in the six cardinal positions of gaze and note any diplopia. Test visual acuity and the visual fields by confrontation, and ask about pain on eye movement. These thyroid eye signs are extrathyroidal manifestations of Graves disease. ^[1]
6. Inspection of the neck. With the neck slightly extended and in good light, look for scars, asymmetry, venous prominence and a visible thyroid swelling. Ask the patient to take a sip of water and swallow, and watch for movement of the swelling with the swallow; both thyroglossal cysts and thyroid tissue move upwards, but only a thyroid cyst is fixed by tongue protrusion (a thyroglossal cyst moves up with tongue protrusion because of its embryological attachment to the hyoid). Then ask the patient to stick the tongue out and cough, watching for the same upward movement. Note whether the trachea appears deviated by inspection, or more reliably by palpation after the next step.
7. Palpation of the thyroid from behind. Stand behind the patient. Ask them to flex the neck slightly forward and a little to one side to relax the sternocleidomastoid of that side. Palpate with the pads of both hands, starting below the cricoid and working down over each lobe, feeling for the isthmus and then each lateral lobe between the fingers and the cervical spine. Ask the patient to swallow while your fingers are over the lobes and feel for the upward movement of thyroid tissue. Do both sides, then palpate the trachea from the front to judge whether it is central, and palpate the supraclavicular fossae and the cervical lymph nodes from behind.
8. Description of the goitre. If any swelling is present, describe its site (right, left, isthmus or diffuse), its size in two dimensions by measurement or by finger widths, its shape (diffuse enlargement, solitary nodule, or multinodular), its consistency (soft, rubbery, firm or hard), its surface, whether it moves with swallowing, whether it is tethered to skin or strap muscles, and whether it is tender. A clinically palpable thyroid nodule is generally over about 1 cm in size. ^[1] Look for retrosternal extension by percussion over the upper sternum and by Pemberton's sign, in which bilateral arm elevation for at least a minute causes facial flushing, venous engorgement and breathlessness when the goitre compresses the thoracic inlet. ^[1]
9. Auscultation of the neck. Place the bell of the stethoscope over each thyroid lobe, and over the carotid and subclavian arteries for comparison, in a quiet room. Listen for a systolic bruit. A thyroid bruit may be heard in Graves disease because of increased glandular blood flow. ^[1] Explain to the patient what you are doing, and do more than simply announce it; listening without explanation is a common source of alarm.
10. Thyroid status and reflexes. Inspect the skin and hair for the signs in the Table. Test the knee and ankle jerks, paying particular attention to the relaxation phase of the ankle jerk, which is characteristically prolonged and delayed in hypothyroidism. Test proximal power at the shoulders and hips, because proximal myopathy occurs in both hyper- and hypothyroidism. Look at the tongue for macroglossia.
11. Body habitus and appearance. Stand back and look at the patient as they stand or sit. Note premature baldness in men with hypothyroidism, and the three special endocrine appearances described below: ordinary thyroid disease, Cushing syndrome and acromegaly.
12. Examination for diabetes, part one: the feet. Inspect and palpate both feet and legs with the patient lying or seated and barefoot. Note skin temperature and colour, pulses (dorsalis pedis and posterior tibial, counted for 30 seconds), hair loss, dryness, callus, fissure, nail shape, deformity, ulcer and gangrene. Test protective sensation with a 10 g monofilament and vibration with a 128 Hz tuning fork, and test light touch and pain. A Chinese burn and trauma guideline recommends skin, nail, ulcer and neuromuscular assessment of the diabetic foot, with 10 g monofilament and 128 Hz tuning fork testing as part of neuropathy assessment. ^[6]
13. Examination for diabetes, part two: injection sites. Inspect every site the patient has used for insulin, including abdomen, thighs, buttocks, upper arms and any infusion-set area in a patient on a pump. Look for lipohypertrophy and lipodystrophy, bruising, erythema, abscess, nodules, and the cutaneous complications of subcutaneous insulin, and ask the patient to show their current sites.
14. Examination for diabetes, part three: the fundi. Dim the lights and examine both fundi with the ophthalmoscope. Look for microaneurysms, dot and blot haemorrhages, hard waxy exudates, cotton-wool spots, venous changes, neovascularisation at the disc or elsewhere, vitreous haemorrhage, macular oedema and signs of laser treatment. These findings, confirm them with an optometrist or ophthalmologist if you are not certain.
15. Hypoglycaemia. Ask about and observe the autonomic symptoms and signs of hypoglycaemia (pallor, sweating, tremor, palpitations, anxiety) and the neuroglycopenic symptoms and signs (hunger, fatigue, lethargy, confusion, slurred speech, blurred vision, drowsiness, loss of consciousness, seizure). ^[4] A episode at the bedside is recognised clinically and confirmed by capillary glucose; carry glucose gel and do not let presentation delay treatment.
16. Adrenal insufficiency. Look for hyperpigmentation of the palmar creases, buccal mucosa, old scars, abdominal striae? no, those are different; sun-exposed and friction areas, for vitiligo, for wasting and for postural hypotension. Specific bitemporal visual field defects are also sought where a pituitary mass is suspected. Record every negative clearly in a patient with fatigue or weight loss.

Use this Table as the bedside checklist and as the evidence for the presentation. One row equals one finding; quote the numbers you are given with units.

The wording here is a teaching style, not a script. The order is the point.

1. Lead with the most important finding. The first complete sentence should say why this patient matters. Not "This is a 34-year-old woman who has been tired for three months", but "This is a 34-year-old woman with a diffuse, tender goitre, a resting tremor and weight loss, whose thyroid is clinically overactive." Everything else is context.
2. State the summary, then the detail. Say the headline, then the detail that supports it, never the other way round.
3. Group the normal systems. Say "General inspection normal; eyes, lungs and abdomen normal" once, and spend the time on the abnormal. Never list every component you checked when the whole system is normal.
4. State the negatives that matter. If the question is whether this is Graves, say "no exophthalmos, no pretibial myxoedema and no nodules on palpation". If the question is exclusion of malignancy, say "no hard nodules, no cervical lymphadenopathy, no fixation and no hoarse voice". The important negatives must be spoken because on the page they look as though they were not thought of.
5. Quantify. Say "pulse 108 per minute, irregularly irregular, with no radio-radial delay" not "a fast pulse". Say "12 kg weight loss in four months" not "some weight loss". Numbers carry the clinical weight.
6. End with the impression and the important alternatives. One sentence for the most likely: "I think this is Graves disease in a clinically hyperthyroid patient." Then the realistic alternatives in order of likelihood and danger: "toxic multinodular goitre is the alternative, and thyroiditis is possible."
7. Give the plan. State what you think is needed next: thyroid function tests and antibodies, ophthalmology if eye signs are present, a pregnancy test when relevant, and a senior review.

The matching written entry uses the same order and is shorter. Write the headline, the abnormal findings with values and units, the normal systems as a grouped phrase, the impression, the differential and the plan. Record what you did not examine plainly: "Fine needle aspiration and formal visual field testing not performed today."

All examples below are illustrative and use invented patient details and invented findings. They are not transcripts of real patients.

Illustrative normal neck (invented patient). Spoken: "This is Mr Hughes, aged 47, a new surgical inpatient awaiting an elective hernia repair, examined before the operation. He has no symptoms of thyroid disease, diabetes or hypercortisolism; he has gained no weight recently, sleeps and eats normally, and has no eye symptoms. On examination he is well and euthyroid by general inspection, with warm well-perfused hands, no tremor, normal pulse and blood pressure sitting and standing, normal eyes, no proptosis or lid lag, a visible neck scar from a childhood operation, a central trachea and a thyroid that is neither visible nor palpable, no cervical lymphadenopathy and no bruit. His feet, injection sites and fundi are normal, as is the rest of the examination. I think he is clinically euthyroid with a normal thyroid examination, and I would not add any endocrine tests to his preoperative work."

Illustrative Graves disease (invented patient). Spoken: "This is Mrs Naik, aged 34, seen in the outpatient clinic with six weeks of palpitations, heat intolerance, 6 kg weight loss with increased appetite, and loose stools; she smokes 10 cigarettes a day. Her family and menstrual history are normal. On examination she is thin, warm and flushed, with a fine tremor of both outstretched hands and a resting pulse that is irregularly irregular, 88 per minute, with no radio-radial delay and blood pressure 142/80. Her eyes show mild bilateral proptosis, upper lid retraction with sclera visible above both irides and lid lag on downgaze, within normal limits of movement. There is a diffuse, soft, non-tender goitre that moves with swallowing, with no dominant nodule, a central trachea and no cervical lymphadenopathy. She has pretibial myxoedema on both shins, and her ankle jerks are brisk. Her feet, injection sites and fundi are normal. I think this is Graves disease in a clinically hyperthyroid patient; toxic multinodular goitre is unlikely with a diffuse goitre, and thyroiditis is the other alternative. She needs thyroid function tests with thyroid-stimulating hormone receptor antibodies, an ophthalmology referral given her eye signs, and a senior review; I will also ask about pregnancy before arranging any imaging."

Illustrative multinodular goitre (invented patient). Spoken: "This is Mr Bell, aged 61, who noticed a lump in the front of his neck two years ago that has grown slowly; it is not painful and there are no thyroid symptoms. On examination he is clinically euthyroid, with no tremor, normal warm hands, a regular pulse of 72 per minute, normal blood pressure sitting and standing and no eye signs. In the neck there is a visible downward and forward swelling that moves with swallowing, with no upward movement with tongue protrusion; palpation from behind reveals an asymmetric multinodular goitre, larger on the right than the left, with two palpable nodules estimated at 2 cm and 1.5 cm, firm and mobile, no central tracheal displacement and no cervical lymphadenopathy; there is no bruit. His feet, injection sites and fundi are normal. I think this is a euthyroid multinodular goitre, which may be toxic or compressive later in its course; thyroid neoplasm cannot be excluded on palpation alone. He needs thyroid function tests, a thyroid ultrasound, and a senior decision about fine needle aspiration and treatment."

• Examining only the neck. The diagnosis of thyroid status is made from the whole patient. A student who palpates the gland without looking at the hands, pulse, eyes and reflexes has not examined the thyroid.
• Palpating from the front without explaining what you are doing. Frontal palpation often frightens the patient. Stand behind, use both hands, explain the swallow and tongue protrusion, and stay relaxed.
• Calling a normal thyroid "not palpable". "Not palpable" is not the same as "normal"; state that the lobes are smooth and mobile and that the isthmus is not felt, or say it was not fully assessed.
• Forgetting tongue protrusion. A thyroglossal cyst can be mistaken for a thyroid nodule or a small goitre if you only ask the patient to swallow.
• Auscultating without a quiet room and without comparing with the carotids. Background noise and transmitted carotid sounds create false positives.
• Ignoring posterior cervical and supraclavicular nodes. They are the nodes that matter in thyroid and lung disease, and are easily reached from behind while you are already there.
• Writing a nodule as "small". "2 cm, firm, mobile and non-tender" is a description; "small" is not.
• Describing the eyes only when disease is obvious. Upper lid retraction and lid lag are subtle and easy to miss if you do not look for them deliberately in the primary position and on downgaze.
• Forgetting to state the important negatives. In the presentation, a normal eye examination, a central trachea and the absence of a bruit each rule out an important alternative and should be said.
• Not assessing injection sites and feet in a diabetic patient. These areas are often omitted because they are fiddly; they are where the disease is visible.

• The endocrine and thyroid examination is a whole-patient examination, performed to a fixed order, in a warm well-lit room with the patient both seated and standing.
• A clinically palpable thyroid nodule is generally over about 1 cm in size, and any swelling is described by site, size, shape, consistency, mobility and tenderness.
• Palpate the thyroid from behind with the neck slightly flexed; ask the patient to swallow, and ask the patient to protrude the tongue to distinguish a thyroglossal cyst from thyroid tissue.
• A goitre is thyroid tissue when it moves with swallowing; a thyroglossal cyst moves both with swallowing and with tongue protrusion.
• Auscultate with the bell over each lobe in a quiet room, and compare with the carotids; a thyroid bruit suggests increased glandular blood flow, as in Graves disease.
• The hands, pulse, eyes and reflexes establish thyroid status before the neck is palpated: warm moist hands, fine tremor, lid lag and brisk reflexes in hyperthyroidism; dry skin, coarse hair and delayed reflexes in hypothyroidism.
• Thyroid eye signs (proptosis, lid lag, lid retraction, chemosis) and pretibial myxoedema are extrathyroidal manifestations of Graves disease.
• A body habitus that is Cushingoid or acromegalic should be recognised and recorded, as should the bitemporal field defect that signals a compressive pituitary lesion.
• In a patient with diabetes, inspect and test the feet (pulses, sensation, skin, nails and deformity), inspect all injection sites for lipohypertrophy and lipodystrophy, and examine the fundi for diabetic retinopathy.
• Autonomic and neuroglycopenic symptoms diagnose hypoglycaemia; hyperpigmentation, vitiligo, wasting and postural hypotension diagnose adrenal insufficiency, supported by the finding of postural hypotension in about 90 percent of cases.
• A normal thyroid and a euthyroid state are positive clinical findings and should be stated explicitly.
• Presentation of the findings leads with the most important abnormality, groups the normal systems, states the important negatives and numbers, and ends with an impression, a differential and a plan.

Plain-text related topics include: hyperthyroidism; hypothyroidism; Graves disease; Hashimoto thyroiditis; thyroid nodules and malignancy; thyroid function testing and result interpretation; thyroiditis; Cushing syndrome; acromegaly and growth hormone excess; Addison disease and adrenal insufficiency; type 1 and type 2 diabetes mellitus; diabetic chronic complications; diabetic foot disease; diabetes tests (glucose and HbA1c); hypoglycaemia recognition and management; phaeochromocytoma; multiple endocrine neoplasia; cranial nerve examination; cardiovascular examination; presenting a patient orally and in writing; and infection prevention and hand hygiene. These MedGrasp topic links are listed as plain text until the corresponding pages are verified.