Hypothyroidism

Symptoms and Signs Hyperthyroidism

General Neuro General Neuro
From asymptomatic to myxedema coma • Depression “Like running a marathon all the time” • Nervousness
“Like everything is slowed down” • Memory loss • Appear to have high energy but are • Restlessness
• Low exercise tolerance • Fatigue fatigued • Insomnia
• Hyperlipidemia • poor exercise tolerance • Tremour
• Cold intolerance • Heat intolerance


Face/Neck
Face/Neck • ophthalmopathy
Ø  ocular changes (periorbital
• Hair is coarse, brittle and is lost swelling, lid retraction and lid lag,
• Thinning of lateral 1/3 of eye brows stare and infrequent blinking)
Ø  infiltrative (proptosis/
• Puffy Face exophthalmos, increased edema
• Enlarged tongue of lids and conjunctiva, chemosis,
ophthalmoplegia)
• Hoarseness
• ± Goitre
• ± Diffuse goitre
• Bruit (when osculating over thyroid)

• Weight gain (modest)

• Weight loss (despite appetite)

Cardiovascular
• pericardial effusion Cardiovascular
• bradycardia
• Palpitations, Afib
• cardiomegaly • hypertension

GI Gu: GI Gu:
•  Constipation • Menorrhagia •  Diarrhea • Infertility, amenorrhea

Skin Skin
• Skin is dry, coarse, thick, cold, • Sweating
pale • Warm, moist skin
Muscles • Dermatopathy
• Weakness, cramps Ø  Hands: Acropachy
Ø  Legs: “pretibial myxedema

* Seen in Graves
• Tendon Reflex Delay (relaxation phase)
• Increased Reflexes

[Link] Other: Onycholysis, gynecomastia,palmar erythema,spider angiomata, myopathy,
periodic paralysis, vitiligo

 Approach to Thyroid Masses

HPI
• History of Significant Radiation Exposure (Chernobyl nuclear TSH
accident in 1986, external beam radiation treatment to the head
and neck for other cancers like lymphoma, radiation facial acne
treatment in 1950s)
• Voice change (neck mass compressing the recurrent laryngeal
Low Normal High
nerve)

FH:
• Family history (esp. medullary thyroid cancer)
T4 US +/- FNA
PE:
•  physical findings associated with an increased risk malignancy:
•  Size >4 cm
•  Male Thyroid
•  Age <20 or >60 Scan (RAIU)
•  Rapid growth
•  Lymphadenopathy
•  Hoarse voice, voice change, or vocal cord paralysis
•  Mass is fixed or tethered and does not move with swallowing “Hot” “Cold”

FNA

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 Approach to Hypothyroid Approach to Hyperthyroid

↓TSH/
↑ TSH ↑T4

No other tests needed à Likely Hashimotos Bypass and Clinically ? RAIU +

treat Significant Scan

Sub Acute
Graves Nodule Thyroiditis

Uptake ↑ ↑ ↓

Scan Diffuse Hot Nodule N

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 Problems
Exposure of tissues to subnormal
amounts of thyroid hormone

• Fetus and neonate: defective
neuronal development
• Childhood: decreased growth
Function Can have overlap Structure
and development
• All ages: decreased metabolic
activity, increased
mucopolysaccharide depositions Size:
Hypothyroidism Hyperthyroidism Enlarged Nodule(s)
(Goitre)

Under- Other: Functional

Destruction production Surgery Congenital
Causes Benign Malignant
Subclinical

Eg.
• cyst • Papillary
Lack of
Pituitary
• colloid nodule thyroid
cancer (PTC)
Drive • Follicular
thyroid
cancer (FTC)
Radioactive Toxic Toxic Exogenous • Medullary
Hasimoto’s Hypopituitarism
Iodine
Medications Graves’ Nodular Nodule
Thyroiditis Hormone Other thyroid
Iodine Deficiency
cancer (MTC)
• Anaplastic
• autoimmune Inflammation of • choriocarcinoma or cancer
• Most common, • Iodine/drug disorder (can
• Iodine deficiency induced 131I •TSI bind to thyroid causing release hydatidiform moles (HCG) • Metastatic
90% women also be
Autoimmune
• Absence of goître
• Food containing
treatment hTSH-R
thyroid
of preformed
hypo) • thyroid carcinoma (toxic from other
stimulating thyroid hormone that carcinomatous nodule or primary
Plasma cells and cassava has anti- immunoglobulin is usually self-limiting from widespread metastasis) (breast, GI
lymphocytic thyroid properties (TSI) • struma ovarii cancers)
infiltration • Improves with Acute infectious (rare) • associated with • Lymphoma
Positive thyroid sodium iodide acromegaly arising in the
antibodies treatment Subacute • related to polyostotic thyroid
Commonly no local
symptoms Granulomatous
Thyroiditis (common)
fibrous dysplasia
• induced by iodine

• likely viral • TSH-producing pituitary
• Small, diffuse, firm
• three phases: adenoma
goiter
1) hyperthyroid • T3 toxicosis
• Hypothyroidism
2) hypothyroid
• Family history of
3) recovery phase

autoimmune

diseases or
• treatment: NSAID or
other thyroid
prednisone for
diseases
pain, b-blocker for
Can be
hyperthyroid,
symptoms, L-T4 not
usually necessary


Postpartum thyroiditis:
•lymphocytic thyroiditis
up to 1 year
post-partum, usually 6
weeks afterdelivery
•usually mild phases of
hyper(initial)/
hypothyroidism

• antimicrosomal
antibodies elevated
•usually resolves but can
recur after future
pregnancies

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