Assessment

HISTORY. The patient may describe a history of constipation, fatigue even with little activity, weight gain with decreased food intake, aches and stiffness, generalized weakness, slowing of intellectual functions, impaired memory, and loss of initiative. Often, patients describe cold intolerance and, if hypothyroidism is accompanied by goiter, discomfort with clothes or jewelry that is close fitting around the neck. The patient may complain of hair loss or slow growing of hair and nails. Women may note heavy, irregular menstrual periods, and men may describe impotence. Both may experience decreased libido.

Determine if the patient's diet is deficient in iodine. Some foods (cabbage, spinach, radishes) and medications (antithyroids, lithium carbonate) can cause hypothyroidism in a person predisposed to the disease. In addition, medications such as digoxin and insulin are potentiated by the hypothyroid state.

PHYSICAL EXAMINATION. The patient has signs of a slowed metabolism and a slow tendon-reflex relaxation. Note a slow speech pattern, flat affect, and difficulty in forming replies to interview questions. The patient may have a dry, thick tongue and hoarseness; dry, flaky skin with a pale or yellowish tint; and edema of the hands and feet. Fingernails and toenails may appear thick, grooved, and brittle. The patient's face may have a distinctive appearance, with thick features, a masklike appearance, edema around the eyes, drooping eyelids, and abbreviated eyebrows. The patient's hair is often thin and dry; patchy hair loss is common.

On palpation, the skin feels cool, rough, and "doughy." You may not be able to feel the thyroid tissue unless the patient has a goiter. Weak peripheral pulses, distant heart sounds, and hypotension are common findings. The patient has either decreased or absent bowel sounds and may have abdominal distension. Other findings include hypothermia, shortness of breath, and either depressive or agitated mood states. Rare findings include hypoventilation, pericardial or pleural effusions, deafness, and carpal tunnel syndrome.

PSYCHOSOCIAL. The patient's behavior may be depressed, agitated, disoriented, or even paranoid. You may notice intellectual slowing and impaired interactions with others; family members may be upset about the change in behavior.

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