What review of systems should I perform for a patient suspected of hyperthyroidism?

Review of Systems for Suspected Hyperthyroidism

When evaluating a patient for suspected hyperthyroidism, systematically assess for hypermetabolic symptoms, cardiovascular manifestations, and organ-specific complications that characterize thyrotoxicosis.

Constitutional and Metabolic Symptoms

• Ask about unintentional weight loss despite normal or increased appetite, as this is a cardinal feature of hyperthyroidism reflecting increased metabolic rate 1, 2
• Inquire about heat intolerance and excessive sweating, which occur due to increased thermogenesis from elevated thyroid hormone 1, 2
• Screen for fatigue and generalized weakness, paradoxically common despite the hypermetabolic state 2

Cardiovascular System

• Ask about palpitations, rapid heartbeat, or awareness of heartbeat, as tachycardia is one of the most common cardiovascular manifestations 1, 3
• Screen for chest pain or dyspnea, particularly in older patients where hyperthyroidism can unmask or worsen underlying cardiac disease 4
• Inquire about exercise intolerance or shortness of breath with exertion, as these may indicate developing heart failure from the increased cardiac workload 4, 3
• Ask about irregular heartbeat or "skipped beats", as atrial fibrillation is a serious complication, especially in patients over 50 years 1, 5

Neuropsychiatric Manifestations

• Ask about nervousness, anxiety, or feeling "jittery", which are prominent neuropsychiatric features of thyrotoxicosis 1, 2
• Screen for insomnia or difficulty sleeping, a common complaint in hyperthyroid patients 1
• Inquire about tremor, particularly of the hands, which reflects increased adrenergic activity 3
• Ask about mood changes, irritability, or emotional lability 3

Gastrointestinal System

• Ask about increased frequency of bowel movements or diarrhea, reflecting accelerated gut motility 1, 3
• Inquire about changes in appetite, typically increased but occasionally paradoxically decreased 3

Musculoskeletal System

• Screen for proximal muscle weakness, particularly difficulty climbing stairs or rising from a chair 3
• In Asian patients, specifically ask about episodes of sudden paralysis or weakness in the legs, as thyrotoxic periodic paralysis occurs more frequently in this population 5

Integumentary System

• Ask about changes in skin texture, such as warm, moist, or smooth skin 3
• Inquire about hair loss or thinning hair 3
• Screen for nail changes or separation of nails from nail bed 3

Ophthalmologic Symptoms (Graves Disease-Specific)

• Ask about eye discomfort, grittiness, or excessive tearing, as these suggest Graves ophthalmopathy 1, 3
• Inquire about double vision or changes in vision 1
• Screen for eye bulging or prominence noticed by patient or family members 1, 3
• Ask about sensitivity to light or feeling of pressure behind the eyes 3

Reproductive System

• In women, ask about menstrual irregularities, particularly oligomenorrhea or amenorrhea 3, 2
• Screen for changes in libido or sexual dysfunction in both men and women 2
• In pregnant women, inquire about any pregnancy complications, as untreated hyperthyroidism increases risk of adverse pregnancy outcomes 1, 5

Neck Symptoms

• Ask about neck swelling or awareness of a mass in the neck, which may indicate goiter 6, 3
• In patients with toxic nodular goiter, specifically inquire about dysphagia, orthopnea, or voice changes, as these suggest local compression from an enlarged thyroid 1

Critical Red Flags Requiring Urgent Evaluation

• Screen for symptoms of thyroid storm: fever, severe tachycardia, altered mental status, or agitation, as this is a life-threatening emergency requiring immediate hospitalization 3, 2
• Ask about recent chest pain or new-onset heart failure symptoms in older patients, as cardiovascular complications are the chief cause of death in hyperthyroid patients over 50 years 4

Common Pitfalls to Avoid

• Do not overlook cardiovascular symptoms in elderly patients, as they may present with atypical features such as apathy rather than hyperactivity, and cardiovascular complications are more common in this age group 4, 5
• In patients with underlying heart disease, recognize that even mild hyperthyroidism can precipitate heart failure or atrial fibrillation 4, 3
• Remember that subclinical hyperthyroidism (low TSH with normal T3/T4) can still cause significant cardiovascular and bone complications, particularly in patients over 65 years 2, 5