Lady with hoarse voice

Thickened and coarse facial features, perorbital puffiness
A spot diagnosis in endocrine substation in station 5.

General inspection
** Hoarse voice, response and movements are slow
** Overweight
** Myxoedematous facies as shown in the picture

Check eye for jaundice(?chronic active hepatitis)and pallor (?hemolytic anemia). Don't forget to look for Grave's disease eye signs.

Rub the hair with your fingers to feel for coarse hair.

Check the mouth for macroglossia.

Check the neck for goitre and scar
Don't miss a scar in this case! In PACES, 99.9% of hypothroidism is due to previous total thyroidectomy.

Thyroidectomy scar!
Then, proceed to the hand to count the pulse rate i.e. bradycardia and look for acropachy in Grave's ds.

Test for proximal myopathy over shoulder.

Check for pretibial myxoedema and pedal edema in lower limbs.

Lastly, position the patient in a chair to test the ankle jerk for slow relaxation phase. Remember, this is the most important sign that indicate the patient is clinically hypothyroid!

End your examination by saying that you would complete it by checking CVS, Lung and cerebellar signs.

Learning points:
** Don't miss a scar in hypothyroid patient!
** Always look for Grave's ds signs in hypothroid patient. Remember, the treatment may cause hypothroidism!