Hypothyroidism

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

General examination

To diagnose hypothyroidism a detailed and full general examination is mandatory in the initial assessment of a patient. 

Body habitus, weight and BMI

Weight gain is often associated with hypothyroidism.

Weight loss will also occur with the development of Addison’s disease or with type 1 diabetes mellitus.

Cardiovascular system

Detailed cardiac assessment is necessary.

Bradycardia and other arrhythmias may occur in hypothyroidism.

Orthostatic hypotension may occur, but may also indicate glucocorticoid deficiency with Addison’s disease.

Congestive cardiac failure may complicate both hyperthyroidism and hypothyroidism.

Skin and hair

Dry skin with diffuse hair loss may be seen in hypothyroidism.

Doughy pallid 'myxoedematous' skin may also be seen with loss of thyroid function.

Fine wrinkling of the skin occurs in thyroid dysfunction due to hypopituitarism.

Pallor may also occur with anaemia and glucocorticoid deficiency of any cause, for example pernicious anaemia, coeliac disease or pituitary dysfunction.

Deeply tanned skin with pigmentation of scars may indicate Addison’s disease.

Patches of symmetrical depigmentation of both hair and skin may occur with vitiligo.

Patches of complete hair loss indicate associated alopecia areata.

Pretibial myxoedema - pinkish discolouration over thinned and yellow tinged skin of the shins, with or without oedema - may occur with hypothyroidism.

Eyes

Periorbital oedema may occur in hypothyroidism of any cause but is most commonly seen in Graves' disease.

Any asymmetry suggests Graves' disease as the cause of thyroid dysfunction. More obvious Grave’s ophthalmopathy is indicated by obvious swelling around the eyes, redness of the whites of the eyes (conjunctival injection), protrusion of one or both eyes visible from the side or above the head (proptosis or exophthalmos), incomplete lid closure or ophthalmoplegia.

Hands

Examine the palms - cool, dry hands occur in hypothyroidism.

Reflexes

Slow relaxing reflexes are seen in severe hypothyroidism.

Musculature

Proximal myopathy may occur with loss of thyroid function. Ask the patient to slowly rise from a squatting position with a straight back and without using their arms or levering their upper body to help.

Muscle wasting may also occur in glucocorticoid deficiency.

Thyroid gland, neck and nodes

First inspect the neck from the front and ask the patient to swallow. Diffuse thyroid swelling, nodules, cysts and multinodular goitres may all be obvious as anterior neck masses that move on swallowing.

Examine the neck thoroughly. This is usually performed from behind the seated patient and in a systematic fashion. The texture of the gland, tenderness, and the presence or absence nodularity or of distinct lumps or lymph nodes must be noted.

Ask the patient to swallow while palpating any nodules and check for lymphadenopathy.