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from leakage of thyroid hormones from a gland damaged in trauma or from viral infection in a self-limited
process called thyroiditis. Hypothyroidism (underactive thyroid) most commonly results from autoantibodies
directed against thyroid enzymes, resulting in decreased production of thyroid hormones. Another cause is
inherited defects in thyroid cell function.
Subjective: Symptoms
Simple goiter: Mass in the anterior neck; dysphagia; dysphonia (hoarseness); stridor, cough or wheezing as a
result of compression of the esophagus, recurrent laryngeal nerves or trachea by the goiter.
Hyperthyroidism: Excessive sweating, intolerance of hot temperature, decreased stamina and endurance,
nervousness, irritability, tremor, weight loss, increased size and frequency of bowel movements (hyperdefeca-
tion or diarrhea), palpitations, insomnia, and eye irritation/discomfort. See notes below for comments on
pregnancy and thyroid storm.
Hypothyroidism: Fatigue, depressed mood, excessive sleepiness/reduced alertness, intolerance for cold
temperature, weight gain, hair loss, constipation, and muscle cramps.
Focused History: Quantity: Goiter: Are you aware of a lump in your neck? (Many patients with goiter are
unaware.) Hyperthyroidism: Do you have more bowel movements per day than you did before? (increased
frequency suggests hyperdefecation) Does your heart race at night or does a rapid heart beat wake you
from sleep? (Persistent rapid heart rate is typical.) Have you become thinner or lost weight? (typical)
Hypothyroidism: How many hours are you sleeping each day? How long have you required this much
sleep? Do you fall asleep or feel tired during the day? (increased sleep requirement is typical) Are you
having fewer bowel movements each week than you did before? (Constipation is typical.)
Quality: Mass Effect of Goiter: Do you have any difculty when you breathe in? (stridor) Do you cough
or feel as if you are choking when you lie down? (compressing trachea) Do you have difculty swallowing
solid food like meat? (esophageal compression) Do you have persistent hoarseness or change in your voice?
(compression of vocal cord nerves). Hyperthyroidism: Do you feel “hotter” than other members of your
family and do you feel sick when it is hot? (heat intolerance) Do you feel nervous or irritable most of the time?
Do your hands tremble most of the time? (typical symptoms) Hypothyroidism: Do you notice any change in
your hair? Is it falling out by handfuls? When did you become aware of hair loss? Do you seem “colder”
than other members of your family? (typical symptoms) Do you have trouble concentrating or being alert while
you are working? (decreased state of alertness and mental slowing). Do you have cramps in your legs when
you walk or run? (neuromuscular dysfunction).
Duration: Goiter: How long have you been aware of a mass in your neck? (benign goiter may be present for
many years; sudden appearance suggests possibility of cancer) Do other members of your family have a lump
like this? (benign goiter may manifest heritable thyroid dysfunction). When did you rst begin to feel different
from normal? (sudden onset suggests thyroiditis or a dietary exposure, such as iodine)
Alleviating and Aggravating Factors: Do you feel better and function better when it is warm (or cold)?
Do you feel worse and function worse when it is cold (or hot)? (hypothyroidism: poor tolerance for cold,
hyperthyroidism: poor tolerance for heat)
Objective: Signs
Simple Goiter
Using Basic Tools: Vital signs should be normal.
Inspection: Look for an obvious lump or mass in the anterior neck, below the thyroid cartilage (“Adam’s
apple”).
Palpation: Enlarged, smooth or nodular, eshy or rm to hard mass in the anterior neck, between the thyroid
and cricoid cartilages.
Hyperthyroidism
Using Basic Tools: Vital signs: Tachycardia > 100/min; BP > 140 systolic with diastolic < 80.
Inspection: Fine tremor of hands at rest, wide-eyed stare, proptosis (projecting globe of the eye, creating
a “bug-eyed” appearance).
Palpation: Diffuse or nodular goiter (thyroid enlargement), diaphoresis (warm, moist palms and generalized
increased sweating).
Auscultation: Bruit over thyroid gland or supraclavicular space, systolic ejection murmur (reect increased