Hypothyroidism

The diagnosis of an underactive thyroid gland is confirmed with below normal serum thyroxine levels. Also known as myxoedema.

Has the patient gained any weight unintentionally? 

Many patients with hypothyroidism will gain weight.

Does the patient complain of constipation or other change in bowel habit? 

Constipation frequently occurs in hypothyroidism.

However, coeliac disease may also be associated with auto-immune thyroid disease which may present with a change in bowel habit and weight loss.

Does the patient feel depressed, tearful or more irritable than usual? Have they lost the ability to concentrate? 

Low mood may be associated with a hypothyroidism diagnosis.

Has the patient noticed a change in their energy? 

Many patients with hypothyroidism have a profound lack of energy and complain of feeling tired all the time.

Is the patient sleeping normally or are they more tired than usual? 

Many patients with hypothyroidism will complain of feeling tired, despite sleeping well.

Does the patient feel colder or hotter than other people? 

Cold intolerance is typical with hypothyroidism.

Premature ovarian failure may also be associated with auto-immune thyroid disease and may present with oligomenorrhoea and hot flushes.

Does the patient complain of any changes to their skin or hair? 

Dry, doughy and rough skin often occur in hypothyroidism.

Increased pigmentation may indicate associated Addison’s disease.

Classic changes are of losing the outer third of the eyebrows in hypothyroidism, though diffuse hair loss may also be seen.

Has the patient felt dizzy or faint particularly on rising? 

Postural hypotension may occur with bradycardia and with Addison's disease.

Has there been a change in menstrual cycle? 

Menorrhagia and polymenorrhoea may occur with hypothyroidism.

Is the patient trying to get pregnant or is there a chance they are pregnant now? 

Pregnancy is more likely to be achieved with a normal TSH.

There is some evidence of developmental problems in offspring of mothers with unrecognised hypothyroidism.

Has the patient developed any cardiac or respiratory symptoms? 

Bradycardia is usually asymptomatic, but the patient may complain of 'palpitations'.

Breathlessness on exertion, or swollen ankles might indicate congestive cardiac failure.

Has there been any obvious neck swelling or pain? 

Severe but transient painful neck swelling is suggestive of thyroiditis.

Discomfort from a diffusely enlarged firm gland may occur with Hashimoto’s thyroiditis which may mimic a discrete nodule.

The development of a new swelling within a firm gland raises the possibility of lymphoma or other malignancy.

A short history of thyroid swelling should always alert to the possibility of thyroid cancer and demands ultrasound guided fine needle aspiration assessment.

Has the patient noticed any changes in their eyes? 

Ask specifically whether their eyes have been feeling gritty or dry, as though there is something stuck in them. Have their eyes looked red or puffy at times? Has their appearance or vision has changed?

These symptoms indicate Graves' disease which can occasionally present with hypothyroidism, though usually causes thyrotoxicosis.

Has the patient noticed any change in their voice? 

Long standing hoarseness may occur with hypothyroidism.

However, changes should always alert to the possibility of thyroid cancer particularly anaplastic thyroid cancer and requires urgent assessment.

Is there any family or personal history of thyroid problems or swelling? 

Thyroid cancer, multinodular goitres and auto-immune thyroid disease may all occur more frequently within family members.

Is there any family or personal history of thyroid dysfunction, pernicious anaemia, vitiligo, Addison’s disease, alopecia, diabetes or coeliac disease?

Any of these may be associated with auto-immune thyroid dysfunction.

Has there been any recent intercurrent illness, for example a viral respiratory tract infection? 

Thyroiditis typically follows a viral illness, though this is frequently unrecognised.

Has the patient previously undergone any radioactive iodine treatment, head and neck radiation or were they exposed to Chernobyl fall out? 

Exposure to radiation increases the risk of hypothyroidism and thyroid cancer.

Does the patient smoke? 

Smoking increases the risk and severity of ophthalmopathy in auto-immune thyroid disease.