So now we're going to take a look
at the specific manifestations
some of the characteristic features
also involve a loss
of sympathetic tone.
So what we're going
to see is bradycardia,
that'd be very
In addition, because of the
loss of sympathetic tone,
there's less diaphoresis, there's less
sweat glands activated in your skin.
So patients tend to have dry
skin which you may appreciate
by feeling the palms.
The nails also tend to
be somewhat brittle.
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
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.
Patients also may have a bit
of thickening of the tongue.
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.
you can ask the patient's family members
if they've noticed a significant
change in the patient's voice.
As well as there may be even
puffiness around the face.
These are all the same manifestations
of mukul polysaccharides being deposited
in all these different
tissues in the body.
you tend to have patients have
what's called "hung reflexes".
So when I simply do his
biceps reflex in this case,
I'm getting a biceps
reflex that's subtle.
But in patients with
you'll see the arm go up,
and then it gets hung there.
There's this delayed relaxation
phase in all of the reflexes.
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.
There's so many manifestations
some of which have decent
and other ones are historically
interesting and fun to discover,
but not necessarily
Now, let's move on
And as we talked
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.
in addition to increasing sympathetic tone
is also going to have
regarding to it being
an autoimmune process,
and its predilection for
particular tissues in the body.
So hyperthyroidism in general
is going to have increased
sympathetic tone with tachycardia.
So simply checking some of these heart
rates a pretty good place to start.
you'll have increased
sweating throughout the body.
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.
Next up, we should go ahead and
check this patient's reflexes,
we're going to find some hyperreflexia
in contrast to hyporeflexia.
And this is simply a very
brisk reflex that we might see
as compared to hypothyroidism.
And the last manifestation that
is not regarding Graves' disease,
just hyperthyroidism in general involves
the sympathetic tone to his eyelids.
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.
It's tone is regulated somewhat
by the sympathetic nervous system.
So if you increase tone
that nervous system,
the eyelids are going to
be a little bit elevated.
This can be tested with something
called the lid lag test.
So I'm going to have
him look up at my finger
and keeping your head
Please just follow
my finger down.
You'll note that
as his eyelid fell,
it still kept the sclera
above his pupil obscured.
We could not see any
that white part above his
above his iris.
in a patient with lid lag,
the lid lags, it doesn't fall
as quickly as it ought to.
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.
Now let's talk about
the two manifestations
that are specific
to Graves' disease.
The first of which
which is a fancy way of saying the
eye is bulging out of its sockets.
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.
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
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.
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.
That wraps it up for our
discussion of thyroid disease.
So we can move on
to the next section.