- Delayed ankle jerks (the single best clinical indicator for hypothyroidism)

- Maroni sign = hyperthyroid, redness and itchiness of skin over thyroid

- Berry Sign = The absence of carotid pulsation w/ malignant thyroidmegaly

Congenital Abnormalities
- Lingual thyroid
o Thyroid fails to descend during embryogenesis
- Heterotropic Thyroid Tissue
o Nests of thyroid tissue found along the pathway of its descent into the
lower neck
- Lateral Aberrant thyroid
o Ectopic thyroid tissue in the lymph nodes and soft tissue adjacent to the
normal gland
- Thyroglossal duct cyst
o Failure of the thyroglossal duct to completely involute resulting in a
cystic, fluid-filled remnant

Non-toxic Goiter
- Simple or Diffuse Nontoxic Goiter (Euthyroid)
o Enlargement of the thyroid gland without evidence of thyroid dysfunction
o Asymptomatic, if symptomatic there is smooth neck mass
o Serum T3, T4 and TSH normal, normal or high RAIU
- Multinodular Nontoxic Goiter (Euthyroid)
o Enlargement of the thyroid gland without evidence of thyroid dysfunction
o Multiple nodules and/or cysts have developed
o Serum T3, T4 and TSH normal, normal or high RAIU
o Asymptomatic, but may progress to thyrotoxicosis = hyperthyroidism
- Euthyroid Sick Syndrome
o Abnormal thyroid function tests in a normally euthyroid patient, suffering
from severe nonthyroidal systemic illness
o Decreased T3, decreased or normal T4, variable TSH, increased cortisol

Hypothyroidism
- Congenital Cretinism (congenital myxedema)
o A congenital condition caused by a deficiency of thyroid hormone during
prenatal development because mother is deficient in iodine and
characterized in childhood by dwarfed stature, mental retardation,
dystrophy of the bones, and a low basal metabolism. Also called
congenital myxedema.
o T3 and T4 low, TSH High unless lack of TSH secretion

Primary Hypothroidism, Non-Goitrous

- Hashimoto’s Thyroiditis
o Chronic thyroid inflammation caused by autoimmune factors
 o Serum TSH elevated but free T4 is normal
o Course of illness: get myxedema (puffy face and eyelids, hand and foot
edema) then severe agitation known as myxedema madness, get
constipation, heart problems and reproductive problems
o Serum cholesterol often high in primary hypothyroidisms
o Primary hypothyroidisms have a history of menorrhagia (heavy menstrual
bleeding)
o Complications are myxedema coma
- Subacute Thyroiditis (aka Granulomatous, Giant Cell or de Quervain’s
Thyroiditis)
o An acute inflammatory thyroid probably caused by a VIRUS
o Self-limited hyperthyroid phase, followed by transient hypothyroidism and
eventual recovery to euthyroid sate
o “Sore throat” (progressive neck pain) and low grade fever
o Early phase increased T3 and T4, decreased TSH, high ESR
o Late phase decreased T3 and T4, low TSH
- Silent Thyroiditis
o A subacute disorder occurring most commonly in the postpartum period
o Self-limited hyperthyroid phase, followed by transient hypothyroidism and
eventual recovery to euthyroid state
o WBC count and ESR normal

- Goitrogenic Vegetables = cabbage, turnips, sweet potato and kelp

o Goitrogenic d/t suppression of thyroid hormone synthesis

Primary Hypothryroidism, Goitrous

- Iodine Deficiency
o Dietary iodine deficiency
o TSH may be slightly elevated, T4 may be low, normal or high, T3 is
normal or slightly elevated
- Iodide Induced
o Goiter induced through excessive iodine consumption

Hyperthyroidism
- Grave’s Disease (aka Basedow disease in Europe)
o Autoimmune disorder, diffure goiter, hypermetabolism and exopthalmus
o Proptosis (forward displacement of eyeball)
o Lid lag and lid retraction, Heat intolerance
o Low TSH, except in those w/ an anterior pituitary tumor
o Opthalmopathy is specific to Graves: orbital pain, lacrimation,
photophobia, double vision, exopthalmos
o Pretibial myxedema shows non-pitting tibial edema and rarely occurs in
the absence of Grave’s opthalmopathy
- Toxic Multinodular Goiter (Plummer-Vinson Syndrome)
o Hyperfunctioning thyroid nodules
 o Same presentation as Graves but without the opthalmopathy and pretibial
edema
o Focal accumulation of radioiodine in one or more nodules
o Eexogenous T4 does NOT suppress uptake of iodine
o T4 and T3 often only minimally ↑, and RAI uptake normal or slightly ↑
- Toxic Adenoma
o Solitary, hyperfunctioning follicular neoplasm in an otherwise normal
thyroid
o Scan shows a solitary focus of iodine uptake “HOT NODULE” in a
background of minimal inake
o Not dependent on TSH and not suppressed by hormone administration
- Hypersecretion of TSH
o Rare cause of hyperthyroidism: pituitary adenomas that secrete TSH, and
or ↑ hypothalamic secretion of TRH
- Iodine Induced
o Treatment with iodine can lead to hypersecretion
- Thyroid Storm
o Abrupt onset of the more florid sx of hyperthyroidism
o Thyroid storm is a life-threatening emergency requiring specific tx
o Fever, Weakness and muscle wasting, Extreme restlessness, Wide emotions
swings, Confusion
o Psychosis, Coma, Hepatomegaly w/ jaundice

Neoplasms – Benign
- Follicular Adenoma: Solitary Cold Nodules
o Asymptomatic neck mass
o Hot nodules are benign in 98% of cases
o Whereas 5-10% of cold nodules are malignant
o Order serum calcitonin in pt who have a family hx of medullary thyroid
carcinoma

Neoplasms – Malignant
- Papillary Carcinoma
o 75% of US thyroid cancers
o Most common thyroid cancer, can metastasis to lungs
o Painless palpable nodule in otherwise normal gland or
o Nodule w/ enlarged cervical LN or
o Cervical lymphadenopthy in the absence of a palpable thyroid nodule
- Follicular Carcinoma
o 15% of all thyroid cancers
o Follicular carcinoma differs from papillary in being solitary and rarely
occult, metastasis goes mainly to the bones of the shoulder, pelvis,
sternum and skull
o Palpable nodule or enlarged thyroid
- Anaplastic Carcinoma
 o 10% of all thyroid cancers
o highly aggressive, undifferentiated carcinoma
o Presents as large, poorly circumscribed mass, often extending into
surround tissue
o Tends to invade veins and arteries producing infarction w/in the tumor
o Dysphagia, dyspnea
- Medullary Carcinoma
o 5% of all thyroid cancers
o From C-cells, patients with familial form often affected with MENII
o Usually presents as a frim thyroid nodule or as cervical lymphadenopathy
o Extend by direct invastion into soft tissue and mets to LN, LU, LV and
bones
- Thyroid Lymphomas
o 2% of all thyroid cancers
o 95% are B-cell tumors
o Large masses, usually extending beyond the gland