40 Thyroid disorders

Questions

Patients with thyroid disease typically present with symptoms of hyperthyroidism, hypothyroidism or a thyroid enlargement (Table 3.40.1). Patients with a goitre may be hyperthyroid, euthyroid (neutral) or hypothyroid (Fig. 3.40.1). Goitres can give rise to mechanical problems: palsy of the recurrent laryngeal nerve (hoarseness), tracheal compression (stridor) and oesophageal compression (dysphagia) (Fig. 3.40.2).

Feature	Hyperthyroid	Hypothyroid
General	Thin, anxious, wasted facial muscles	Overweight, lethargic, slow speech, hoarseness
Hands	Sweating Fine tremor, seen if the hands are outstretched Thyroid acropachy: thyroid finger clubbing associated with Graves’ disease Onycholysis: nail is lifted out of its bed (also in psoriasis) Palmar erythema	Cold and dry; the fingertips may be blue Non-pitting oedema of congestive heart failure
Pulse	Tachycardia, atrial fibrillation	Bradycardia
Eyes	Exophthalmos: protruding eyes as a result of retro-orbital oedema; sclera is visible all the way around the iris Lid retraction: raised upper eyelid where sclera is not visible all the way around the iris Proptosis: the eye protrudes forward so far it is visible beyond the supraorbital ridge when viewed from above Chemosis: periorbital oedema with redness Lid lag when performing eye movements: on vertical gaze (possible double vision) Opthalmaplegia occurs as eye movements are weak (especially upward gaze)	Enophthalmos: loss of the outer third of the eyebrow
Reflexes	Brisk reflexes at the knee	Slow relaxing reflexes
Ankles	Pre-tibial myxoedema: thickening of the tissues in front of tibias (rare)	Signs of non-pitting oedema of congestive heart failure
Thyroid hormones
Free T₃ or T₄	↑	↓
Total T₃ or T₄	↑	↓
TSH	↓	↑