Physical Exam Findings in Hypothyroidism, Hyperthyroidism, and Graves' Disease

by Stephen Holt, MD, MS

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    00:01 So now we're going to take a look at the specific manifestations of hypothyroidism and hyperthyroidism.

    00:08 With hypothyroidism, some of the characteristic features also involve a loss of sympathetic tone.

    00:14 So what we're going to see is bradycardia, that'd be very common manifestation.

    00:17 In addition, because of the loss of sympathetic tone, there's less diaphoresis, there's less sweat glands activated in your skin.

    00:25 So patients tend to have dry skin which you may appreciate by feeling the palms.

    00:30 The nails also tend to be somewhat brittle.

    00:33 In addition, this is more related to the lack of thyroid hormone itself, we're going to have diffuse hair loss, which may be subtle in patients, but it's not specific to one area like with alopecia androgenetica.

    00:46 You tend to have loss of hair just at the vertices of the scalp, whereas with hypothyroidism, it can be more diffuse and distributed throughout.

    00:55 Patients also may have a bit of thickening of the tongue.

    00:58 They'll also have because they have some thickening of the vocal cords, they can have somewhat of a gravelly, nasally sound to their voice.

    01:05 And oftentimes, you can ask the patient's family members if they've noticed a significant change in the patient's voice.

    01:11 As well as there may be even puffiness around the face.

    01:14 These are all the same manifestations of mukul polysaccharides being deposited in all these different tissues in the body.

    01:21 And lastly, with hyperthyroidism, you tend to have patients have what's called "hung reflexes".

    01:27 So when I simply do his biceps reflex in this case, I'm getting a biceps reflex that's subtle.

    01:35 But in patients with hyperthyroidism, you'll see the arm go up, and then it gets hung there.

    01:39 There's this delayed relaxation phase in all of the reflexes.

    01:45 Lastly, some of the more nuanced, less common findings would be something like Queen Anne's sign, where you actually lose the outer third of the eyebrows.

    01:53 There's so many manifestations of hypothyroidism, some of which have decent test characteristics, and other ones are historically interesting and fun to discover, but not necessarily diagnostically useful.

    02:06 Now, let's move on to Hyperthyroidism.

    02:09 And as we talked about hyperthyroidism, it's really important to categorize those manifestations that are related to the increased sympathetic tone that accompanies hyperthyroidism due to excess catecholamine activity versus those manifestations that are specific to Graves' disease.

    02:25 Graves' disease, in addition to increasing sympathetic tone is also going to have some manifestations regarding to it being an autoimmune process, and its predilection for particular tissues in the body.

    02:35 So hyperthyroidism in general is going to have increased sympathetic tone with tachycardia.

    02:41 So simply checking some of these heart rates a pretty good place to start.

    02:44 In addition, unlike hypothyroidism, you'll have increased sweating throughout the body.

    02:50 So patients tend to be very diaphoretic they tend to have warm skin due to increased tone in the skin itself phase a motor tone in the skin.

    02:59 Next up, we should go ahead and check this patient's reflexes, we're going to find some hyperreflexia in contrast to hyporeflexia.

    03:06 And this is simply a very brisk reflex that we might see as compared to hypothyroidism.

    03:14 And the last manifestation that is not regarding Graves' disease, just hyperthyroidism in general involves the sympathetic tone to his eyelids.

    03:25 Remember that the levator palpebrae muscle has innervation from the sympathetic nervous system, even though it's also a voluntary muscle that we can contract.

    03:32 It's tone is regulated somewhat by the sympathetic nervous system.

    03:36 So if you increase tone that nervous system, the eyelids are going to be a little bit elevated.

    03:41 This can be tested with something called the lid lag test.

    03:44 So I'm going to have him look up at my finger and keeping your head still, Shawn.

    03:50 Please just follow my finger down.

    03:52 You'll note that as his eyelid fell, it still kept the sclera above his pupil obscured.

    03:59 We could not see any that white part above his above his iris.

    04:05 However, in a patient with lid lag, the lid lags, it doesn't fall as quickly as it ought to.

    04:10 So you'll actually catch some of that white sclera above his iris and that would be a characteristic feature of the increased sympathetic tone associated with hyperthyroidism.

    04:20 Now let's talk about the two manifestations that are specific to Graves' disease.

    04:24 The first of which involves exophthalmos, which is a fancy way of saying the eye is bulging out of its sockets.

    04:32 And what's happening there is that there's these proteoglycans that are being deposited in the ocular motor muscles behind the eye that are therefore pushing the eye forward.

    04:42 And sometimes this can be best seen by simply just looking from the side of a person's head and you'll be able to see the eyeball more protuberant or coming forward than you otherwise would normally.

    04:54 And the second manifestation that is specific to Graves' disease is so called pretibial myxedema, which is the palpation of these doey subcutaneous nodules in the pretibial areas.

    05:07 And this again has to do with excess proteoglycan deposition in the soft tissue of the anterior surfaces of the shins, just just a characteristic feature of this autoimmune disease.

    05:18 That wraps it up for our discussion of thyroid disease.

    05:22 So we can move on to the next section.

    About the Lecture

    The lecture Physical Exam Findings in Hypothyroidism, Hyperthyroidism, and Graves' Disease by Stephen Holt, MD, MS is from the course Examination of the Head and Neck Region.

    Included Quiz Questions

    1. Diffuse hair loss
    2. Tachycardia
    3. Weight loss
    4. Excessive sweating
    5. Hyperreflexia
    1. Lid lag
    2. Hyporeflexia
    3. Dry, cool skin
    4. Brittle nails
    5. Nasal voice
    1. Pretibial myxedema
    2. Weight gain
    3. Decreased sympathetic tone
    4. Bradycardia

    Author of lecture Physical Exam Findings in Hypothyroidism, Hyperthyroidism, and Graves' Disease

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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