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Lecture
for 4th year medical students at the Faculty of Medicine King Fahad
Medical City, Riyadh, on December 21, 2013
1.0 FUNCTIONAL DIAGNOSES
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Hypothyroid (slow down)
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Euthyroid
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Hypethyroid (speed up)
2.0 BASIS OF DIAGNOSIS (+ and -)
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History of presenting symptoms
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Clinical thyroid assessment
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Measurements of blood thyroid
hormone levels
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Antibody studies
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Thyroid imaging (thyroid
technetium nuclear medicine scan, thyroid ultrasound)
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Thyroid fine needle biopsy
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Pathognomonic signs (spot
diagnosis)
3.0 STRUCTURED HISTORY
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Demographic data: age, date,
residence / water supply (iodine)
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Presenting symptoms / signs:
background, the 5 questions, previous episodes, current medication,
consequences / disabilities
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Risk Factors
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Medical history
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Surgical history:
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Family history
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Social history / habits: Usual
diet , Smoking, Alcohol, Drugs including Analgesics, Occupation, education,
hobbies, Marital status, social support, Living conditions
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System review: cardiovascular,
respiratory, gastrointestinal, skin, musculoskeletal (growth and development),
reproductive, sensory and nervous etc
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Closing the interview
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Summary: what are the main
problems?
4.0 PRESENTING SYMPTOMS OF HYPERTHYROIDISM
(thyrotoxicosis)
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Skin: excessive sweating, itching,
heat intolerance
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Nervous: Increased irritability, emotional lability, malaise
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Cardio vascular: Palpitations,
dyspnea
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Musculoskeletal: weakness, tremor
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Gastro-intestinal: increased
appetite, thirst, vomiting, diarrhea, increased bowel movements, weight Loss
despite a good appetite
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Reproductive: menstrual
disturbances, loss of libido, gynecomastia
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Children: excessive height /
growth
5.0 PRESENTING SIGNS OF HYPERTHYROIDISM
(thyrotoxicosis)
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Enlarged thyroid gland (goiter): diffuse
(generalized) or focuses and nodular - Pressure effects: dysphagia, more for
solids than liquids - Dypnea, chocking sensation - Neck pain due to
inflammatory conditions - Malignancy: voice change die to laryngeal nerve
infiltration, hard neck lymph nodes,
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Cardiovascular: tachycardia,
atrial fibrillation, warm vaso-dilated extremities, systolic HT, cardiac
failure
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Eye: Exophthalmos (proptosis), eye
lid retraction (white sclera seen above iris when patient looks forward), eye
lid lag (upper eye lid lags behind the eyeball when patient is asked to look at
finger moving from up downwards), diplopia, ocular pareses, conjuctival edema
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Musculoskeletal: Fine tremor of
hands, muscle weakness (patient has difficulty rising up from sitting squatting
position)
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CNS: Looks anxious, cannot sit
still, irritable, psychosis,
6.0 RISK FACTORS OF HYPERTHYROIDISM
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Auto immune: Graves' disease
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Toxic nodular goiter:
multinodular, solitary
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Acute thyroiditis - rare
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Gestational thyrotoxicosis - rare
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Neonatal thyrotoxicosis - rare
7.0 PRESENTING SYNPTOMS OF HYPOTHYROIDISM
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Lethargy, somnolence,
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Loss of concentration and memory
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Cold intolerance
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Parasthesia
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Deafness and unsteadiness
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Muscle and joint pains / aches
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Angina, intermittent claudication
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Un explained weight gain
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Constipation
8.0 PRESENTING SIGNS OF HYPOTHYROIDISM
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Hypothermia
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Thyroid shrunken
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Slowness and sluggishness
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Voice: husky, deep
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Skin: dry and cold, thick
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Face: puffy with peri-orbital
edema and bags under eyes
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Non pitting myxedema
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Tendon jerks have a slow
relaxation phase
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Cerebellar dysfunction with
difficulty in balance
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Reproductive: Menorrhagia,
infertility, recurrent abortion, galactorrhoea
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GIT: Intestinal obstruction, Paralytic
ileus,
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Peripheral edema
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Hair: dry, coarse, brittle
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Children: slow growth, poor school
performance
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Nervous system: coma, depression
9.0 RISK FACTORS OF
HYPOTHYROIDISM
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Congenital: agenesia, ectopic
thyroid remnants
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Defective hormone synthesis:
iodine deficiency, drugs (anti thyroid, lithium, amiodarone, interferon)
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Auto immune: atrophic thyroiditis,
Hashimoto’s thyroiditis, post partum thyroiditis
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Infective: post sub acute
thyroiditis
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Post irradiation / Post surgery
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Tumor
infiltration
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Hypopituitarism
·
Peripheral
resistance to thyroid hormone
10.0 SCORING SHEET (THYROID HISTORY)
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Item
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Gp1
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Gp2
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Gp3
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Gp4
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Gp5
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Gp6
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Gp7
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Gp8
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Gp9
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Gp10
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Introduction
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Demographics
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Presenting Complaints
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Risk factors
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Medical history
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Surgical history
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Family history
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Social history
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System review
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Closing
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Summary
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NB: Score: 0=not done 1=done not well
2=done well