A 66-year-old widow complained "I can't hear good". Although she could not date the onset of decreased hearing, she had experienced difficulty listening over the telephone for at least a year. When a daughter who had not seen her mother for two years visited her, she noted several things that were unusual for her mother. The house was unkempt (her mother had been a compulsive housekeeper) and quite warm (the thermostat was set at 78-80 ° F during the winter months). Her mother's affect seemed to be more jovial and her voice huskier than the daughter had remembered. The patient, however, denied any real changes and had no specific complaints other than decreased hearing. She occasionally had numbness in both hands early in the morning that cleared by 10 AM, and at times had some cramping in her calves at night. She denied any constipation (bowel movement every 2-3 days), shortness of breath, use of any medications, or chronic pain. She had been treated with I 131 for hyperthyroidism fifteen years ago; no other significant medical or family history was elicited.
This pleasant woman weighed 145 lb with a height of 62 inches. Blood pressure was 150/100, pulse 60/minute and regular, and temperature 97.8 ° F. The skin was dry and flaky with a yellow tinge, particularly over the soles of the feet. HEENT exam showed no cerumen in the auditory canal, normal tympanic membranes, and Weber test was nonlateralizing. She did not hear the ticking of a watch held against either pinna. The upper eyelids were puffy, and extraocular movements were normal. The tongue was questionably enlarged. Her voice was husky and her speech was slow. The thyroid was not palpable. Neurologic exam revealed a woman who moved slowly and who answered questions appropriately, but it took awhile to get the answers. No motor or sensory deficits were found, but there was a delay in the relaxation of the deep tendon reflexes. The remainder of the examination was normal.