BY
USGAOKAR KAPIL K
CLINICAL CLERK
AMEC BCCM
DEFINITION
• Hypothyroidism is the most common disorder
arising from thyroid hormone deficiency.
Classification
• According to the time of onset it is divided in
congenital and acquired
• According to the level of endocrine
dysfunction in primary and secondary or
central
• According to the severity into severe/ overt/
clinical and mild or subclinical
hypothyroidism.
AUTOIMMUNE HYPOTHYROIDISM
• Associated with a goiter (Hashimoto’s, or goitrous
thyroiditis) or, at the later stages of the disease,
minimal residual thyroid tissue (atrophic thyroiditis)
• Incidence - 4 per 1000 women, 1 per 1000 men,
(21.94% of the population had autoimmune thyroiditis
(1)
• Mean age of diagnosis - 60 years
• Pathogenesis – lymphocytic infiltration, atrophy of
thyroid follicles with oxyphil metaplasia, absence of
colloid and mild to moderate fibrosis.
• Risk factors – genetic, environmental
• Markers – antibodies to TPO & Tg, antibodies against
TSH - R
ETIOLOGY
SIGNS & SYMPTOMS OF HYPOTHYROIDISM
(descending order of frequency )
Symptoms Signs
Tiredness, weakness Dry coarse skin, cool peripheral extremities
Dry skin Puffy face, hands, and feet (myxedema)
Feeling cold Diffuse alopecia
Hair loss Bradycardia
Difficulty concentrating and poor memory Peripheral edema
Constipation Delayed tendon reflex relaxation
Weight gain with poor appetite Carpal tunnel syndrome
Dyspnea Serous cavity effusions
Hoarse voice
Menorrhagia (later oligomenorrhea or
amenorrhea )
Parasthesia
Impaired hearing
MANAGEMENT
PRIMARY HYPOTHYROIDISM – Levothyroxine, monitor TSH levels
SUBCLINICAL HYPOTHYROIDISM – Levothyroxine if patient wants to
conceive/ pregnant/ TSH > 10 mIU/L, if not then monitor TSH levels
annually
SECONDARY HYPOTHYROIDISM – Levothyroxine, monitor free T4
MYXEDEMA COMA - Levothyroxine (500 μg) as a single IV bolus
followed by daily treatment with levothyroxine (50–100 μg/d),
along with hydrocortisone (50 mg every 6 h) for impaired adrenal
reserve, ventilator support, space blankets, and treatment of
precipitating factors.
PHYSICAL EXAMINATION IN
GENERAL SURVEY
Data Significance
Level of consciousness /state of awareness Lethargy (hypothyroidism in Hashimoto’s
thyroiditis, silent thyroiditis)
Height and weight Weight gain (feature of hypothyroidism)
Weight loss (present in Toxic MNG)
Manner of speech and tone of voice Hoarseness and husky voice could be
present in some thyroid mass or goiter
Mood
VITAL SIGNS
Data Significance
BP Hypertension – feature of thyrotoxicosis which could also
be present in TMNG
Hypotension- can been seen in hypothyroidism ( feature
of thyroiditis with enlarged thyroid)
Heart Rate Tachycardia (thyrotoxic feature of TMNG)
Bradycardia (feature of hypothyroidsim in some thyroiditis
with enlarged thyroid)
Respiratory rate Tachypnea- to assess for thyroid mass that may affect
manner of breathing
Temperature Finding of fever can include inflammatory condition or
infection of the thyroid gland
SKIN
Data Significance
Dry, coarse skin May be seen in hypothyroidism with
thyroid mass
Moist skin, warm skin May be seen in thyrotoxicosis with
enlarged thyroid gland
HEENT
Data Significance
Ask for pain in ears Painful thyroid (thyroid pain) may
radiate to ears
Eye signs of thyrotoxicosis To consider thyroid mass/ goiter with
features of hyperthyroidism
Inspect and palpate thyroid gland To note for the size, shape and
consistency of gland and nodules
Ask for pain and difficulty of swallowing
Auscultate for bruit or stridor Bruit heard in hyperthyroidism
HEENT
ICCIDD/ WHO CLASSIFICATION OF GOITER
GRADE DESCRIPTION
0 No goiter
1A Thyroid lobes larger than the ends of the thumbs
1B Thyroid enlarged, visible only with head tilted back
2 Thyroid enlarged, visible with head in normal position
3 Thyroid enlarged, easily visible from a distance of 10
meters
HEART
Data Significance
Assess for arrhythmia (sinus May be present goiter with
tachycardia) or atrial fibrillation thyrotoxicosis
Assess for pericardial and pleural May be present in thyroid mass with
effusion hypothyroidism features
GASTRO INTESTINAL TRACT
Data Significance
Ask for hyperdefecation or diarrhea Present in goiter/ thyroid nodules with
features of hyperthyroidism
Ask for constipation Present in thyroid mass with
hypothyroidism features
GENITOURINARY SYSTEM
Data Significance
Assess for menorrhagia or May be present in features of
amenorrhea hypothyroidism or hyperthyroidism in
some thyroid nodules or mass
MUSCULOSKELETAL SYSTEM
Data Significance
Assess for muscle weakness Can be present in both features of
hyperthyroidism and hypothyroidism
in thyroid nodules or mass
