Thyroid and Parathyroid Conditions C&P Exam Prep

TSH (Thyroid-Stimulating Hormone)

What it measures: Reflects pituitary signal to the thyroid; elevated TSH indicates hypothyroidism, suppressed TSH indicates hyperthyroidism

What to expect: The examiner will review your most recent TSH lab result from your medical records or may order one. Normal range is approximately 0.4-4.0 mIU/L.

Pain considerations: N/A - TSH is a laboratory test; however, if labs are drawn at the exam, report any anxiety or symptoms you experience during the process

Free T4 (Free Thyroxine)

What it measures: Active thyroid hormone level; low Free T4 confirms hypothyroidism, elevated Free T4 confirms hyperthyroidism

What to expect: Examiner will review existing labs. Normal range is approximately 0.8-1.8 ng/dL.

Pain considerations: N/A - laboratory test

Free T3 (Free Triiodothyronine)

What it measures: Active form of thyroid hormone at the cellular level; relevant in hyperthyroidism and T3 toxicosis

What to expect: Reviewed from existing records. Normal range is approximately 2.3-4.2 pg/mL.

Pain considerations: N/A - laboratory test

Thyroid Antibodies

What it measures: Detects autoimmune thyroid disease (TPO antibodies for Hashimoto's; TSI/TRAb for Graves' disease)

What to expect: Examiner will review existing antibody results. These support the diagnosis of autoimmune thyroid disease.

Pain considerations: N/A - laboratory test

Parathyroid Hormone (PTH) and Calcium Levels

What it measures: PTH controls calcium regulation; elevated PTH with hypercalcemia indicates hyperparathyroidism; low PTH indicates hypoparathyroidism

What to expect: Examiner will review existing PTH, total calcium, and ionized calcium results. These are critical for rating hyperparathyroidism severity.

Pain considerations: If hypocalcemia causes muscle cramps, tetany, or spasms, describe the frequency, severity, and any emergency treatments needed

Heart Rate and Blood Pressure

What it measures: Vital signs reflecting autonomic and cardiovascular impact of thyroid dysfunction; tachycardia common in hyperthyroidism, bradycardia possible in hypothyroidism

What to expect: The examiner will record your heart rate and blood pressure as part of the physical exam.

Pain considerations: Report any chest pain, palpitations, shortness of breath, or exercise intolerance associated with your thyroid condition

Deep Tendon Reflexes (DTR)

What it measures: Neurological examination assessing reflex responses at biceps, triceps, brachioradialis, knee (patellar), and ankle - hypothyroidism can cause delayed (hung) reflexes; hyperthyroidism can cause hyperreflexia

What to expect: Examiner will test reflexes bilaterally using a reflex hammer. Results will be graded (0 = absent to 4+ = hyperactive).

Pain considerations: If reflex testing causes discomfort due to muscle tenderness or joint pain, communicate this to the examiner

Thyroid Physical Examination (Palpation)

What it measures: Assesses gland size, texture, presence of nodules, symmetry, and post-surgical changes including scar tissue

What to expect: The examiner will palpate your neck to assess the thyroid gland. They will note whether it is normal, enlarged (goiter), nodular, tender, or absent/surgically altered.

Pain considerations: If neck palpation causes pain or tenderness, say so clearly during the exam

100%

Hypothyroidism: Myxedema (cold intolerance, muscular weakness, mental disturbance, and characteristic skin changes) with or without complications; or with cardiac involvement

From 38 CFR: 38 CFR 4.119, DC 7903: Myxedema with or without complications, or with cardiac involvement - 100%

60%

Hypothyroidism: Fatigability, constipation, and mental sluggishness. For hyperparathyroidism: hypercalcemia indicated by bone mineral density T-score - -3.0, ionized calcium > 5.6 mg/dL, total calcium > 12 mg/dL, or creatinine clearance < 30 mL/min

From 38 CFR: 38 CFR 4.119, DC 7903: Fatigability, constipation, and mental sluggishness - 60%. Hyperparathyroidism with severe hypercalcemia indicators - 60%

30%

Hypothyroidism: Fatigability, constipation, or mental sluggishness (one or more symptoms present but less severe than 60% level). Hyperparathyroidism: hypercalcemia with bone mineral density T-score between -2.5 and -3.0, or symptoms controlled with medication but still present

From 38 CFR: 38 CFR 4.119, DC 7903: Fatigability, constipation, or mental sluggishness - 30%

10%

Hypothyroidism: Continuous medication required (hypothyroidism controlled on replacement therapy with minimal or no persistent symptoms). Thyroiditis with normal thyroid function: rated 0% under DC 7906 unless manifesting as hypo- or hyperthyroidism.

From 38 CFR: 38 CFR 4.119, DC 7903: Continuous medication required - 10%. Note: Thyroiditis with euthyroid state = 0% under DC 7906, but if manifesting as hypothyroidism evaluate under DC 7903.

Fatigue and Energy Levels

How to describe it: Describe fatigue in concrete, functional terms. Explain how many hours per day you feel functional, how often you need to rest, and what activities you cannot complete due to exhaustion. Tie fatigue to specific work, household, or social limitations.

Example: On my worst days, I cannot get out of bed until mid-morning even after 10 hours of sleep. I am too fatigued to cook, shower, or leave the house. Any small task like grocery shopping requires a 2-hour rest afterward. This happens 3-4 times per week.

Examiner listens for: Frequency, severity, impact on activities of daily living, whether fatigue is constant vs. episodic, and relationship to thyroid medication dosing or lab abnormalities

Avoid: Do not say 'I'm just a little tired sometimes' - describe how fatigue limits specific functions. Do not say 'I manage fine' if you have reduced your activities, quit your job, or rely on others because of exhaustion.

Cognitive and Mental Symptoms (Mental Sluggishness)

How to describe it: Describe specific cognitive problems: slowed thinking, difficulty finding words, poor memory, inability to concentrate on tasks, problems following conversations or reading. Give concrete examples from work or daily life.

Example: I struggle to follow conversations at work and frequently lose my train of thought mid-sentence. I used to manage complex spreadsheets but now make errors I never would have before. I forget appointments and have to write everything down or I lose track of it completely.

Examiner listens for: Whether mental sluggishness is truly disabling vs. mild inconvenience, impact on occupational function, and whether the veteran has been evaluated for or diagnosed with thyroid-related cognitive impairment or depression

Avoid: Do not minimize brain fog as 'just forgetfulness.' If cognitive changes have cost you a job, reduced your work hours, or required accommodations, state this explicitly.

Cold Intolerance and Temperature Regulation

How to describe it: Describe how you feel in cold environments, whether you wear extra layers compared to others, whether cold prevents you from going outside or functioning normally. Describe impact on sleep and daily comfort.

Example: I wear a heavy sweater and socks indoors year-round. In winter I cannot tolerate being outside for more than a few minutes. I sleep with multiple blankets and a heating pad. My hands and feet are always cold and numb, even when others around me are comfortable.

Examiner listens for: Severity and pervasiveness of cold intolerance, whether it is year-round or seasonal, and how it limits daily function or occupation

Avoid: Do not say 'I get cold sometimes' - explain how cold intolerance interferes with work, social activities, or daily routines in a concrete way.

Muscle Weakness and Musculoskeletal Symptoms

How to describe it: Describe specific muscle groups affected, difficulty with tasks requiring strength or stamina (climbing stairs, lifting, walking distances), and any muscle pain or cramping. For hypoparathyroidism, describe tetany, muscle spasms, and tingling.

Example: My legs feel so weak some days that I have to use the handrail to get up the stairs. I can't carry grocery bags from the car without stopping to rest. I have muscle cramps in my calves and hands that wake me from sleep 2-3 nights per week.

Examiner listens for: Specific muscle groups affected, functional limitations, whether weakness is constant or episodic, and whether it is associated with lab abnormalities (low calcium, thyroid hormone levels)

Avoid: Do not omit muscle cramps or tetany if you have hypoparathyroidism - these are ratable symptoms. Do not say 'I'm just out of shape' if weakness is disproportionate to your activity level.

Cardiovascular Symptoms (Palpitations, Tachycardia, Dyspnea)

How to describe it: For hyperthyroidism or Graves' disease, describe heart palpitations, racing heart, shortness of breath, chest discomfort, and any cardiac diagnoses (atrial fibrillation, thyroid heart disease). Specify frequency, duration, and triggers.

Example: My heart races even when I'm sitting still - it can hit 130 beats per minute at rest. I wake up at night with my heart pounding. I get winded walking to my mailbox. I was seen in the ER twice for palpitations in the past year.

Examiner listens for: Heart rate at exam, reported frequency of palpitations or tachycardia, any cardiac diagnoses secondary to thyroid disease, and whether cardiovascular symptoms warrant a separate cardiac DBQ

Avoid: Do not omit ER visits, hospitalizations, or cardiac diagnoses related to thyroid disease. Hyperthyroid heart disease (DC 7008) can be rated separately under cardiovascular codes.

Eye Symptoms (Graves' Ophthalmopathy / Exophthalmos)

How to describe it: Describe eye bulging (exophthalmos/proptosis), double vision (diplopia), blurred vision, dry eye, eye pain, or light sensitivity if present due to Graves' disease or thyroid eye disease. Note any treatments received for the eyes.

Example: My eyes protrude noticeably and strangers comment on it. I have double vision when looking to the left that prevents me from driving. My eyes are dry and painful every morning. I had a corneal ulcer treated last year.

Examiner listens for: Presence of exophthalmos or proptosis, visual disturbances including diplopia or blurred vision, corneal involvement, and whether eye conditions warrant separate evaluation under 38 CFR 4.79 (e.g., DC 6090 for diplopia)

Avoid: Do not fail to mention eye symptoms if you have Graves' disease - per 38 CFR 4.119 Note (3), eye involvement must be separately evaluated under the eye schedule and can add significant combined rating points.

Gastrointestinal Symptoms (Constipation, Nausea, Anorexia)

How to describe it: Describe bowel habits specifically: how many days between bowel movements, whether laxatives are required, severity of nausea, and any unintentional weight changes from anorexia or hyperthyroid-related weight loss.

Example: I go 5-7 days without a bowel movement even with daily stool softeners and laxatives. The bloating and abdominal cramping are constant. I have no appetite and have lost 18 pounds in the past 6 months without dieting.

Examiner listens for: Whether GI symptoms are directly tied to the thyroid condition, frequency and severity of constipation, and whether weight changes reflect metabolic dysfunction

Avoid: Do not omit constipation or anorexia - these are specifically listed in the 30% and 60% rating criteria for hypothyroidism. Do not minimize them as 'manageable.'

Skin and Hair Changes

How to describe it: Describe characteristic skin changes of hypothyroidism (dry, coarse, thickened, non-pitting edema - myxedema) or hyperthyroidism (warm, moist, fine hair, pretibial myxedema in Graves'). Describe surgical scars in detail if present.

Example: My skin is so dry and thick it cracks and bleeds. My hair has thinned dramatically - I lose handfuls when I shower and my hairline has receded significantly. The skin on my neck is thickened and tight from surgery and feels numb.

Examiner listens for: Classic myxedematous skin changes supporting a 100% rating, scar characteristics (size in cm-, induration, disfigurement of face/neck), and whether skin symptoms warrant a separate dermatology DBQ

Avoid: Do not overlook surgical scars - the DBQ specifically evaluates scar size, induration, inflexibility, tissue loss, and whether there is disfigurement of the head, face, or neck that may warrant separate rating.

Functional Impact on Work and Daily Life

How to describe it: Explain specifically how your thyroid condition limits your ability to work, maintain employment, perform household tasks, care for yourself or family, socialize, and sleep. Quantify limitations with specific examples and durations.

Example: I had to reduce my work schedule from full-time to part-time because I cannot concentrate for more than 2-3 hours before my cognitive function deteriorates. I cannot stand for long periods due to muscle weakness, eliminating jobs that require physical activity. I have missed an average of 2 days of work per month due to fatigue and GI symptoms.

Examiner listens for: Occupational impairment, whether the veteran has lost jobs or reduced hours, the number of days per month symptoms are limiting, and specific activities of daily living that are affected

Avoid: Do not say 'I manage' or 'I push through it' without explaining what that costs you. If you have quit a job, declined promotions, or needed workplace accommodations, state this explicitly.