Goiter is an enlargement of the thyroid gland (Figure 12-2). This enlargement may be uniform throughout the gland or diffuse. Enlargement may also occur in the form of nodules or nodular goiter. A goiter can cause difficulties in swallowing and/or breathing and may or may not be associated with hormonal disturbances. The most common cause is lack of iodine in the diet. Goiters due to iodine deficiency are rare in the United States since the introduction of iodized salt.

Hypothyroidism is diminished production of thyroid hormone, manifested by low metabolic rate, tendency toward weight gain, somnolence, and sometimes myxedema. Myxedema is a skin and tissue disorder that is usually due to severe, prolonged hypothyroidism (Figure 12-3). Symptoms include dull, puffy, yellowed skin; coarse, sparse hair; periorbital edema; and prominent tongue.

Hashimoto’s disease is an inflammation of the thyroid gland that often results in hypothyroidism. It is most common in women and individuals who have a family history of thyroid disease. Onset of Hashimoto’s is slow, and it may not be detected for years. The most common signs and symptoms of Hashimoto’s disease include the following:

Hyperthyroidism (Figure 12-4) is an abnormality of the thyroid gland in which secretion of thyroid hormone is usually increased and is no longer under the regulatory control of hypothalamic-pituitary centers.

Graves’ disease, the most common form of hyperthyroidism, occurs as the result of an autoimmune response that attacks the thyroid gland, resulting in overproduction of the thyroid hormone thyroxine. Graves’ disease is most common among women between 20 and 40 years of age. The most common signs and symptoms include the following:

Graves’ ophthalmopathy is also fairly common and may result in exophthalmos, or bulging eyes (Figure 12-5). A complication of hyperthyroidism is thyrotoxic crisis or storm. This is a sudden intensification of symptoms combined with fever, rapid pulse, and delirium. Medical attention is required when a crisis episode occurs.

Common causes of a thyrotoxic storm or crisis include a medical illness or infection. Other causes include the following:

There are two major types of diabetes mellitus: type 1 and type 2. These types vary in origin, pathology, genetics, age of onset, and treatment (Table 12-2). Patients with type 1 diabetes are insulin dependent; this condition usually develops early in life. The pancreas produces insulin in very small amounts or not at all. Type 2 diabetes usually is of adult onset. The pancreas continues to produce insulin, but it is not properly metabolized. Occasionally, patients with type 2 diabetes must be treated with insulin so that acceptable glucose levels are maintained; the fact that they are taking insulin does not mean that they are dependent on insulin, or that they have type 1 diabetes. Type 2 diabetes is much more common than type 1; 90% to 95% of diabetic patients have type 2 diabetes. Type 2 diabetes in adolescents and children is a relatively new phenomenon, and statistics are still being collected. Sometimes, diabetes is documented as insulin-dependent diabetes mellitus (IDDM) or non–insulin-dependent diabetes mellitus (NIDDM). Documentation of insulin dependence does not determine the type of diabetes, because a patient with type 2 diabetes may be on insulin. If only IDDM is documented, and type 1 or type 2 is not specified, according to coding guidelines, the default is type 2 diabetes.

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