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Classical symptoms include palpitations, heat intolerance, increased sweating, insomnia, tremulousness, diarrhea, and weight loss. Signs of hyperthyroidism include sinus tachycardia, systolic hypertension, frightened stare, an enlarged goiter, a fine resting tremor, and exophthalmos (only if hyperthyroidism is secondary to Graves disease). Other manifestations may include hyperpigmentation, irregular menses, pruritus, and thinning of hair. Complications that occur over time include osteoporosis, tracheal obstruction or dysphagia (from the goiter), tachyarrhythmias (particularly atrial fibrillation), high output heart failure, anemia, and proximal muscle weakness.


  1. Prevalence, 0.3%.

  2. Hyperthyroidism is actually an endocrine syndrome caused by several distinct pathophysiologic entities (Table 32-2).

Table 32-2.Distinguishing features of several hyperthyroid states.


  1. History and physical exam

    1. Certain findings of hyperthyroidism are quite specific (ie, lid lag and lid retraction) and help rule in the diagnosis (specificity, 99%; LR+, 17−32).

    2. However, clinical findings are not highly sensitive. Therefore, absent clinical findings do not rule out hyperthyroidism.

      1. Goiter is present in 70–93% of cases.

      2. Pulse > 90 bpm is present in 80% of cases.

      3. Lid lag is present in 19% of cases.

      4. Ophthalmopathy is present in 25–50% of patients with Graves disease.

      5. Hyperreflexia is variable depending on the age of the patient.

  2. Elderly patients

    1. Prevalence of hyperthyroidism in the elderly is 2–3%.

    2. Hyperthyroidism often presents atypically in elderly patients. ...

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