What is the comprehensive physical assessment for a patient with suspected hyperthyroidism, including review of medical history, symptoms, and laboratory tests?

Physical Assessment for Hyperthyroidism

The physical assessment for hyperthyroidism should systematically evaluate the thyroid gland itself, cardiovascular manifestations, ophthalmologic findings, and systemic signs of thyrotoxicosis, with particular attention to distinguishing Graves' disease from toxic nodular disease. 1, 2

Thyroid Gland Examination

Palpate for thyroid size, consistency, and nodularity to differentiate between diffuse enlargement (suggesting Graves' disease) and nodular disease (suggesting toxic multinodular goiter or toxic adenoma). 1, 2

• Diffusely enlarged, smooth thyroid gland is characteristic of Graves' disease, affecting 2% of women and 0.5% of men globally. 1
• Palpable nodules or asymmetric enlargement suggest toxic multinodular goiter or toxic adenoma rather than Graves' disease. 1, 2
• Assess for compressive symptoms including dysphagia, orthopnea, or voice changes, which indicate significant thyroid enlargement with local structural compression. 1
• Auscultate for thyroid bruit, which indicates increased vascularity and is highly specific for Graves' disease. 2

Cardiovascular Assessment

Measure heart rate and blood pressure systematically, as cardiovascular manifestations are among the most critical findings requiring immediate management. 2

• Tachycardia (resting heart rate >90 bpm) is a cardinal sign of thyrotoxicosis and requires beta-blocker therapy to prevent cardiovascular events. 2
• Hypertension, particularly systolic hypertension with widened pulse pressure, occurs due to increased cardiac output and decreased systemic vascular resistance. 2
• Assess for atrial fibrillation through pulse palpation and cardiac auscultation, as untreated hyperthyroidism causes cardiac arrhythmias. 1, 2
• Evaluate for signs of heart failure including jugular venous distension, peripheral edema, and pulmonary crackles, as hyperthyroidism can precipitate heart failure. 1, 2

Ophthalmologic Examination

Examine for Graves' ophthalmopathy, which is pathognomonic for Graves' disease and absent in other causes of hyperthyroidism. 1, 2

• Assess for exophthalmos (proptosis), which is bilateral bulging of the eyes specific to Graves' disease. 1
• Evaluate for lid retraction and stare, creating a characteristic wide-eyed appearance in Graves' disease. 1
• Check for lid lag by having the patient follow your finger downward—delayed descent of the upper eyelid indicates thyroid eye disease. 2
• Assess extraocular movements for restriction, particularly upward gaze limitation from inferior rectus muscle involvement. 2

Integumentary and Musculoskeletal Findings

Examine skin and extremities for signs of hypermetabolic state and autoimmune manifestations. 2

• Warm, moist skin with increased sweating reflects increased metabolic rate and heat intolerance. 2
• Fine tremor of outstretched hands is a sensitive sign of thyrotoxicosis affecting the neuromuscular system. 2
• Proximal muscle weakness can be assessed by having the patient rise from a squatting position or raise arms overhead. 2
• Pretibial myxedema (thickened, non-pitting edema over the shins) is specific to Graves' disease, though present in only a minority of patients. 2

Neuropsychiatric Assessment

Evaluate mental status and affect, as thyrotoxicosis significantly impacts the nervous system. 1, 2

• Assess for anxiety, restlessness, and emotional lability, which are common neuropsychiatric manifestations of hyperthyroidism. 1
• Evaluate for hyperreflexia with brisk deep tendon reflexes throughout. 2
• Screen for insomnia and difficulty concentrating, which contribute to decreased quality of life. 1

Gastrointestinal and Weight Assessment

Document weight and assess for gastrointestinal symptoms that reflect the hypermetabolic state. 1, 2

• Measure current weight and document recent weight loss, as unintentional weight loss despite normal or increased appetite is characteristic. 1
• Inquire about increased frequency of bowel movements or diarrhea, which occurs due to increased gastrointestinal motility. 1

Critical Pitfalls to Avoid

• Do not miss thyroid storm, a life-threatening complication requiring immediate recognition through fever >38.5°C, severe tachycardia >140 bpm, altered mental status, and cardiovascular instability requiring multidisciplinary treatment. 2
• Do not overlook atrial fibrillation, which requires immediate beta-blocker therapy and anticoagulation consideration, as untreated hyperthyroidism significantly increases cardiovascular mortality. 1, 2
• Do not assume all hyperthyroidism is Graves' disease—absence of ophthalmopathy, presence of nodules, or lack of diffuse goiter should prompt consideration of toxic nodular disease requiring different management. 1, 2
• Do not delay beta-blocker initiation in patients with tachycardia or hypertension, as early cardiovascular management prevents significant cardiac events. 2