4-33
cardiac output).
Percussion: Brisk deep tendon reexes (reects increased neuromuscular irritability).
Hypothyroidism
Using Basic Tools: Vital signs: Temperature < 97° F; bradycardia < 60/min
Inspection: Pale, thin skin; “droopy” eyelids; loss of lateral eyebrow hair (cutaneous changes are prominent in
advanced hypothyroidism); coarse voice; slow response to questions; depressed affect
Palpation: Diffuse, firm goiter (thyroid enlargement) in anterior neck; cool, dry skin
Percussion: Delayed deep tendon reflex return phase, especially at ankles (return is like a “ratchet”)
Assessment:
Patients with goiters require serum TSH and thyroid hormone measurement, which are not available in the
eld, for accurate differentiation between hyper- and hypothyroidism.
Differential Diagnosis:
Goiter - other anterior neck masses are usually either tumors or benign cysts. Goiter will usually be
distinguished by moving up and down with swallowing, whereas other neck masses remain xed.
Hyperthyroidism - anxiety states, starvation/malnutrition, pheochromocytoma, stimulant drug abuse (cocaine,
amphetamines), and congestive heart failure may produce similar symptoms. The nding of a goiter and the
absence of prior psychiatric history and drug abuse history strongly favors hyperthyroidism.
Hypothyroidism - depression, chronic fatigue syndrome, bereavement, hypothermia, sedative drug abuse
(barbiturates, benzodiazepines, etc) may cause similar symptoms. Most patients with hypothyroidism are
not severely ill, and can begin empiric treatment on a cautious basis. Very sick individuals require urgent
evacuation, including patients in coma and those with profound hypothermia (temperature < 96° F).
Plan:
Treatment
Goiter
Primary: Denitive treatment is dependent on the results of blood tests not available in the eld.
Primitive/Empiric: Lodine supplementation (low dose if in goiter-endemic area)
Hyperthyroidism
Primary: Propranolol 10-40 mg po qid to render pulse < 80/min
Hypothyroidism
Primary: Denitive treatment is dependent on the results of blood tests not available in the eld.
Primitive: Provide warmest possible environmental temperature and encourage maximum physical exertion.
Patient Education
General: Denitive blood testing is an important aspect of care and follow-up is essential to well-being.
Activity: Normal activities are permitted without restriction for patients with simple goiter. Patients with
suspected or conrmed hyperthyroidism should not perform strenuous exercise or employment-related activity
until the condition is improved. Acceptable activities include light duty in a cool (preferably indoor) environ-
ment, and clerical duties.
Diet: Avoid dietary goitrogens (see note below) in patients with simple goiter or hypothyroidism.
Follow-up Actions
Return evaluation: Most patients with minor symptoms can be followed at two to four-week intervals. For
patients with hyperthyroidism, emphasis should be on heart rate control (goal is < 80 beats per minute) and
tremor control.
Evacuation/Consultation Criteria: Severe symptoms, including high fever, confusion or delirium, congestive
heart failure, hypothermia, coma, severe bradycardia, or local compressive symptoms in the neck (especially
choking or stridor) require urgent evacuation to a referral center attended by an endocrinologist.
NOTES: Dietary goitrogens: Cassava meal, cabbage, rutabaga, and turnips impair the action of thyroid