What review of systems should be performed for a patient being evaluated for hyperthyroidism?

Review of Systems for Hyperthyroidism Evaluation

A comprehensive review of systems for hyperthyroidism should systematically assess cardiovascular, neuropsychiatric, gastrointestinal, musculoskeletal, dermatologic, ophthalmologic, and reproductive manifestations, as these organ systems are most commonly affected by excess thyroid hormone.

Cardiovascular System

Cardiovascular symptoms are the most critical to assess, as they represent the chief cause of death in hyperthyroid patients, particularly those over 50 years of age 1.

• Palpitations and tachycardia are among the most common presenting symptoms, with heart rate typically elevated above baseline 2, 3
• Atrial fibrillation occurs more frequently in severe hyperthyroidism (15.8% vs 0-5.4% in milder forms) and represents a serious complication requiring immediate attention 4
• Exertional dyspnea may indicate cardiac decompensation, particularly in older patients with underlying cardiac disease where hyperthyroidism can precipitate heart failure 1
• Chest pain or angina should be specifically queried, as the increased cardiac workload from hyperthyroidism can unmask or worsen ischemic heart disease 1
• Hypertension, particularly systolic hypertension with widened pulse pressure, is characteristic of the hyperdynamic state 3

Neuropsychiatric Manifestations

• Anxiety and nervousness are cardinal symptoms of thyrotoxicosis 2, 5
• Insomnia and sleep disturbances occur frequently 2
• Tremor, particularly a fine tremor of the hands, is a classic physical finding 3
• Emotional lability or irritability should be assessed 3

Gastrointestinal System

• Unintentional weight loss despite normal or increased appetite is a hallmark feature 2, 5
• Diarrhea or increased stool frequency reflects accelerated gastrointestinal motility 2
• Increased appetite is common, though weight loss typically occurs despite this 2

Musculoskeletal System

• Proximal muscle weakness, particularly in the thighs and shoulders, may be present 3
• Thyrotoxic periodic paralysis should be considered, especially in Asian populations, presenting as episodic muscle weakness 5
• Bone pain or fractures may indicate osteoporosis from prolonged hyperthyroidism 2

Dermatologic Manifestations

• Heat intolerance and excessive sweating are characteristic symptoms reflecting increased metabolic rate 2, 3
• Warm, moist skin on examination 3
• Hair loss or thinning may be reported 3

Ophthalmologic System (Graves Disease-Specific)

• Eye symptoms including grittiness, tearing, photophobia, or diplopia suggest Graves ophthalmopathy 2
• Proptosis (exophthalmos) or lid retraction on examination indicates Graves disease 2
• Stare is a characteristic finding in Graves disease 2

Neck/Thyroid-Specific Symptoms

• Goiter or neck swelling should be assessed, with larger goiters (WHO grade 2 or higher) associated with higher recurrence risk 5, 4
• Dysphagia, orthopnea, or voice changes suggest local compression from toxic nodular goiter 2

Reproductive System

• Menstrual irregularities including oligomenorrhea or amenorrhea in women 3
• Decreased libido or erectile dysfunction in men 3
• Pregnancy status must be determined, as hyperthyroidism has significant implications for maternal and fetal outcomes 5

Constitutional Symptoms

• Fatigue or asthenia is paradoxically common despite the hypermetabolic state, and is independently associated with severe hyperthyroidism 4
• Fever may indicate thyroid storm, a life-threatening complication 3

Critical Pitfalls to Avoid

• Do not overlook cardiovascular symptoms in elderly patients, as they may present atypically with apathetic hyperthyroidism, where fatigue and depression predominate over classic hypermetabolic symptoms 1
• Atrial fibrillation may be the sole presenting manifestation in older adults, making thyroid function testing essential in new-onset atrial fibrillation 4
• In patients over 50 years with underlying cardiac disease, hyperthyroidism can precipitate heart failure even without causing overt thyrotoxic symptoms 1
• Thyroid storm requires immediate recognition: look for fever, severe tachycardia, altered mental status, and cardiovascular instability 3, 5