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Difficulty: MediumPhysical Examination Findings

A 3535-year-old woman presents to the outpatient clinic reporting a 33-month history of unintentional weight loss, frequent palpitations, and increased sweating. She also reports feeling unusually anxious and having difficulty sleeping. Her vital signs are temperature 37.2∘C37.2^\circ\text{C} (99.0∘F99.0^\circ\text{F}), blood pressure 138/82 mm Hg138/82\text{ mm Hg}, heart rate 110/min110\text{/min}, and respiratory rate 16/min16\text{/min}. Physical examination reveals a staring gaze and mild exophthalmos. Palpation of the neck demonstrates a symmetrically enlarged, non-tender thyroid gland, and a vascular bruit is auscultated over the gland. Her skin is warm and moist. Which of the following additional physical examination findings is most specific for the underlying cause of this patient's condition?

  1. Non-pitting, indurated edema over the anterior lower legsAnswer
  2. B
    Delayed relaxation phase of the Achilles tendon reflex
  3. C
    Ipsilateral facial muscle twitching upon tapping the cheek
  4. D
    Exquisite tenderness of the thyroid gland to gentle palpation
  5. E
    Multiple distinct, firm nodules palpable within the thyroid parenchyma

Answer

Non-pitting, indurated edema over the anterior lower legs
The patient's presentation of hyperthyroidism accompanied by a diffuse goiter, a thyroid bruit, and exophthalmos heavily points to a diagnosis of Graves' disease. Graves' disease is an autoimmune disorder characterized by thyrotropin receptor antibodies. A highly specific physical examination finding for Graves' disease is thyroid dermopathy, which classically presents as pretibial myxedema. This appears as a non-pitting, indurated, sometimes nodular edema over the anterior aspect of the lower legs caused by the localized deposition of glycosaminoglycans.

Step-by-Step Solution

1
Analyze the clinical presentation and initial physical examination findings.
The patient has signs of hyperthyroidism (tachycardia, weight loss, diaphoresis) combined with exophthalmos, a diffuse goiter, and a thyroid bruit.
Identifying the clinical syndrome is necessary to narrow down the differential diagnosis.
2
Establish the most likely diagnosis.
The unique combination of hyperthyroidism, a thyroid bruit, and exophthalmos is highly specific for Graves' disease.
Graves' disease is an autoimmune condition characterized by thyrotropin-receptor antibodies that stimulate the thyroid and cause characteristic extrathyroidal manifestations.
3
Identify additional physical examination findings specific to this diagnosis.
Graves' disease uniquely features dermopathy, most commonly presenting as pretibial myxedema (non-pitting edema on the anterior shins).
Confirming the diagnosis requires differentiating Graves' disease stigmata from other causes of thyrotoxicosis.

Key Concept

The physical examination findings of Graves' disease include a diffusely enlarged goiter with a bruit, ophthalmopathy (exophthalmos, lid lag), and dermopathy (pretibial myxedema).
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Physical Examination Findings

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