What should be included in a physical exam note for a patient with hypothyroidism on levothyroxine (thyroxine)?

Physical Examination Documentation for Hypothyroidism Patients on Levothyroxine

A comprehensive physical examination for patients with hypothyroidism on levothyroxine should focus on assessing treatment adequacy through evaluation of vital signs, thyroid gland characteristics, and signs of over or undertreatment across multiple body systems, with particular attention to cardiovascular, neurological, and dermatological findings. 1

Vital Signs

• Temperature: Document any hypothermia (undertreatment) or hyperthermia (overtreatment)
• Heart rate: Note bradycardia (undertreatment) or tachycardia (overtreatment)
• Blood pressure: Record hypertension or hypotension
• Weight: Document recent changes (weight gain suggests undertreatment, weight loss suggests overtreatment)

General Appearance

• Mental status: Alertness, orientation, cognitive function
• Energy level: Note fatigue or hyperactivity
• Skin: Assess for:
  • Dryness, coarseness, scaliness (undertreatment)
  • Warm, moist skin (overtreatment)
  • Myxedematous changes (undertreatment)
  • Hair texture and distribution
  • Nail changes

Head, Eyes, Ears, Nose, Throat (HEENT)

• Eyes: Check for:
  • Periorbital edema (undertreatment)
  • Exophthalmos, lid lag, lid retraction (overtreatment or Graves' disease history) 1
  • Visual fields assessment (especially with history of pituitary issues)
• Face: Document facial puffiness or myxedematous facies (undertreatment)
• Oral cavity: Note tongue size (macroglossia in undertreatment)

Neck

• Thyroid gland: Document:
  • Size (enlarged, normal, or atrophic)
  • Consistency (firm, soft, nodular)
  • Tenderness
  • Presence of surgical scars
• Lymph nodes: Note any cervical lymphadenopathy

Cardiovascular

• Heart sounds: Document rate, rhythm, murmurs
• Peripheral pulses: Note strength and symmetry
• Extremities: Check for:
  • Edema (especially pretibial in undertreatment)
  • Temperature (cold in undertreatment, warm in overtreatment)
  • Capillary refill time

Respiratory

• Respiratory rate and effort
• Lung sounds: Document any pleural effusions (undertreatment)

Neurological

• Deep tendon reflexes: Document:
  • Delayed relaxation phase (undertreatment)
  • Hyperreflexia (overtreatment)
• Muscle strength: Note proximal muscle weakness (undertreatment)
• Coordination and gait: Document any abnormalities
• Tremor: Fine tremor suggests overtreatment

Gastrointestinal

• Abdominal examination: Document distension or ascites (undertreatment)
• Bowel sounds: Note hypoactive (undertreatment) or hyperactive (overtreatment)

Musculoskeletal

• Muscle bulk and tone: Document any atrophy or weakness
• Joint examination: Note any arthralgia or joint effusions

Documentation Example

PHYSICAL EXAMINATION:
Vitals: T 98.2°F, HR 72, BP 128/78, RR 16, Weight 165 lbs (stable from last visit)
General: Alert, oriented, no apparent distress
Skin: Normal moisture and texture, no myxedematous changes
HEENT: No periorbital edema, no exophthalmos, no lid lag
Neck: Thyroid not palpable, no nodules, surgical scar well-healed from prior thyroidectomy
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs
Respiratory: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended
Extremities: No edema, normal temperature
Neurological: DTRs 2+ and symmetric with normal relaxation phase, normal muscle strength 5/5 throughout, no tremor

Common Pitfalls and Caveats

• Physical examination alone cannot reliably diagnose hypothyroidism or assess treatment adequacy; laboratory tests (TSH, free T4) are essential 2
• Approximately 25% of patients on levothyroxine with normal TSH levels may still experience persistent symptoms, particularly fatigue 3
• Elderly patients require more careful assessment for cardiac complications from potential overtreatment 1
• Document medication adherence issues, as approximately 28% of patients may be non-adherent to levothyroxine therapy 4
• Note timing of medication intake, as only 39% of patients take levothyroxine correctly (≥30 minutes before eating) 4
• Document any medications that may interfere with levothyroxine absorption 1

Remember that physical examination findings should always be correlated with laboratory results (TSH, free T4) for proper assessment of treatment adequacy in hypothyroid patients on levothyroxine.