Hypoechoic nodules grade IV are suspicious malignant nodules with a higher chance of malignancy ratio, usually with a risk of malignancy of 2%-90%, and have the characteristics of malignant nodules. A malignant nodule has five major features: a solid nodule, a hypoechoic or very hypoechoic nodule, a fuzzy irregular border, a microcalcification, and an aspect ratio greater than 1. A grade IV thyroid nodule with 3-4 of the five malignant nodule features requires further examination, either cytology or a puncture biopsy, to clarify the nature of the pathology and then consider the next step in treatment. The nodules have a low degree of malignancy, and surgical treatment is effective.