Introduce, explain and expose

Inspect

• Survey quickly (exophthalmos, myxoedematous facies, lid lag, ankle oedema, tremor)
• Place a piece of paper onto the back of the patient's outstretched hands to better assess for a fine tremor
• Ask patient to stand with their arms crossed assessing for proximal myopathy
• Neck from front: masses, scars (can be subtle)
• Glass of water present (for pt to swallow)
• If mass present see if it moves up on swallowing water: “take a sip of water and hold in your mouth... now swallow”
• Stick out tongue (thyroglossal cyst)
• Look in mouth for lingual thyroid

Palpate

• Pulse for AF
• Trachea: is the trachea central?
• From behind palpate lymph nodes systematically : supraclavicular, submandibular, submental, pre-auricular, post-auricular, suboccipital, posterior triangle, occipital.
• Are the LNs matted/fixed/hard (neoplastic), if there are LNs but no goitre examine axillae and groin nodes (Hodgkin's)
• Palpate both thyroid lobes for lumps: solitary, multiple or diffuse enlargement of whole gland.
• Thyroid dimensions: dimensions (eg. large), edge (behind sternum), surface (Graves=smooth, or nodular), consistency (soft=Graves, firm=multinodular, hard=ca)
• Ask the patient to swallow some water: does it move up on swallowing?

Percuss
Travel up sternum and on clavicles for dullness (may indicate retrosternal extension)

Auscultate
Bruit (in thyrotoxic pt if very vascular thyroid).
Ask pt to take deep breath in then out then stop first

Closing
Thank the patient
Ensure they are comfortable
Wash you hands
Present your findings