Clinical picture:
(A) General Manifestation:
[1] Nervous System
Insomnia. "The 1st symptom"
Tremors in outstretched hand, protruded tongue
Hyper reflexia.
In severe cases may end in mania.
[2] Cardio-vascular manifestations:
Dyspnea on exertion may occur before insomnia
Pulse: Tachycardia
Arrhythmia: all types except heart block
­ pulse pressure ® water hammer plus = hyper dynamic circulation
Bl. pr.:­ systolic & ¯ diastolic = ­pulse pressure
In late severe cases ® Heart failure & oedema of L.L.
[3] Metabolic changes:
High basal metabolic rate.
Excessive sweating with intolerance to heat
Loss or weight inspite of polyphagia "dd with diabetes"
[4] Gastrointestinal symptoms:
Diarrhea, colic due to increased cholinergic activity
[5] Urinary:
Polyuria Glucosuria due to anti-insulin effect of T4.
[6] Genital:
Female: Menorrhagia, polymenorrhea (early) oligomenorrhea or even amenorrhea (late)
Male: ­ in sexual desire (libido) (early) ¯ in sexual desire or even impotence (late)
[7] Skin manifestation:
Flushing of the skin (Warm wet hand) d.d with neurotic patient (cold wet hand)
Hair ® coarse & fall
Pretibial myxedema: (In late cases under antithyroid therapy) It start as shiny red plaque of thickened skin which may be cyanotic when exposed to cold. In severe cases the whole leg below knee is involved (Thyroid acropathy)
[8] Muscloskletal system:
Osteoporosis Wasting of muscle (thyroid myasthenia)
[9] Eye changes:
Exophthalmos due to: (Theories not sure)
a) Exophthalmos producing substance EPS secreted with T.S.H
b) L.A.T.S.H. HOW?
i) Retrobulbar oedema ii) ­ size of the globe
iii) Spasm of Muller’s muscle in eye lid.
Other eye signs:
1) Staring look, rim of white sclera bet upper eye lid and cornea (Dalyrimble’s sign).
2) Lid lagging (Von-Graefe’s sign)
3) Infrequent blinking (Stelwag’s sign)

4) Lack of convergence (Mobius’ sign)
5) Lack of corrugation of the forehead when looking to the ceiling (Joffray’s sign)
In certain circumstances ® Malignant Exophthalmos ® corneal ulceration ® Endothalmitis ® loss of the eye.
Diplopia may occure due to weakness of extraoccular muscles (Inf. oblique). This effect on extraoccular muscles may be antibody mediated effect.
(B) Local manifestation (Thyroid)
Symmetrical enlargement (moderate)
Smooth surface Firm in consistency
Very vascular evidenced by: warm with dilated vein with thrill and machinery murmur.
Sometimes, there are no local signs ® Masked thyrotoxicosis. (old patient, no proptosis, thyrotoxic myasthenia, thyrotoxic heart dis.)
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