Head to toe findings in both hypoyhyroidism and hyperthyroidism
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I now have comprehensive data from multiple authoritative textbooks. Let me compile the full head-to-toe comparison.
Head-to-Toe Findings: Hypothyroidism vs. Hyperthyroidism
Here is the classic diagram of hypothyroidism signs and symptoms from Tintinalli's Emergency Medicine:
HEAD & FACE
| Region | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| General facies | Dull, expressionless, puffy ("myxedema facies") | Alert, anxious, "staring" expression |
| Eyes | Periorbital puffiness / non-pitting edema | Exophthalmos (proptosis), lid lag, lid retraction, periorbital edema (Graves-specific) |
| Eyebrows | Loss of outer 1/3 of eyebrow (Hertoghe's sign) | Normal or thinned |
| Skin of face | Pale, cool, dry, coarse; facial bloating | Warm, moist, flushed; melasma of cheeks possible |
| Hair | Coarse, brittle, sparse; diffuse alopecia | Fine, soft ("downy"), diffuse non-scarring alopecia |
| Tongue/mouth | Macroglossia (enlarged tongue) | Normal |
| Voice | Hoarseness (infiltration of vocal cords) | Normal |
| Hearing | Sensorineural hearing loss in severe cases | Normal |
NECK
| Region | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Thyroid | Goiter may be present (firm/granular/tender depending on cause); or small/impalpable | Diffuse goiter (Graves), nodular goiter (Plummer), or single toxic nodule |
| Lymph nodes | Normal | Usually normal |
CARDIOVASCULAR
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Heart rate | Bradycardia | Tachycardia; palpitations |
| Blood pressure | Diastolic hypertension (50% increased peripheral vascular resistance); 20-40% have HTN | Systolic hypertension; widened pulse pressure |
| Cardiac output | Decreased (30-50% reduction in resting cardiac output) | Increased (high-output state) |
| Rhythm | Normal or bradycardia | Atrial fibrillation (common, especially in elderly) |
| Heart sounds | Distant (pericardial effusion); low voltage on ECG | Prominent, hyperdynamic; increased S1 |
| Other | Angina, pericardial effusion, cardiomyopathy, CHF in severe disease | Cardiac hypertrophy, pulmonary hypertension, CHF, angina (in pre-existing IHD) |
RESPIRATORY
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Breathing | Hypoventilation; pleural effusions | Exertional dyspnea, decreased exercise tolerance |
| Airway | Upper airway obstruction from glottic/vocal cord edema, macroglossia | Normal |
| Chest exam | Decreased breath sounds if pleural effusion | Generally normal |
ABDOMEN / GASTROINTESTINAL
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Bowel sounds | Absent or decreased (constipation) | Increased (hyperdefecation); shortened small bowel transit |
| Stools | Constipation | Frequent loose stools (not usually true diarrhea) |
| Nausea/vomiting | Uncommon | Can precede thyrotoxic crisis |
| Weight | Weight gain (decreased appetite paradoxically) | Weight loss (increased basal metabolic rate) |
| Liver | Normal | Mild aminotransferase elevation; in severe cases marked hepatic dysfunction |
REPRODUCTIVE / ENDOCRINE
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Menstruation | Menorrhagia (heavy periods); infertility | Oligomenorrhea or amenorrhea |
| Lactation | Galactorrhea (elevated prolactin from TRH) | Not typical |
| Libido/fertility | Decreased; infertility | Decreased libido; reduced fertility |
| Adrenal | Normal cortisol (primary) or decreased (secondary hypothyroidism) | Normal |
MUSCULOSKELETAL
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Muscles | Myopathy, muscle cramps, weakness, stiffness | Proximal myopathy, weakness |
| Joints | Arthralgia, joint stiffness | Arthralgia |
| Wrists | Carpal tunnel syndrome | Normal |
| Bones | Normal in adults | Increased bone turnover; osteoporosis risk long-term |
| Acropachy | - | Thyroid acropachy (Graves only): digital clubbing, soft-tissue swelling of hands/feet, periosteal reaction of long bones (~0.1-1%) |
SKIN & APPENDAGES
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Texture | Cool, rough, dry, coarse; thickened | Warm, moist, smooth, velvety |
| Color | Pallor; yellowish tinge (carotenemia) | Palmar erythema; facial flushing; bronzed/melanoderma |
| Sweating | Decreased (anhidrosis) | Hyperhidrosis (excessive sweating) |
| Nails | Brittle; Ragged nails | Plummer's nails - onycholysis (distal separation), concave plate shape (~5%) |
| Vitiligo | - | Present in 7% of Graves disease patients |
| Edema | Non-pitting myxedema (glycosaminoglycan deposition in subcutaneous tissue) - seen at ankles, hands, face | Pretibial myxedema (Graves-specific): bilateral localized glycosaminoglycan plaques below knees, nodular/plaque/elephantiasic forms |
Photo - Thyroid acropachy and pretibial myxedema in Graves disease:
Photo - Non-pitting myxedema (hypothyroidism):
NEUROLOGICAL / PSYCHIATRIC
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Mental state | Fatigue, lethargy, depression, cognitive impairment, psychosis ("myxedema madness") | Anxiety, irritability, emotional lability, hyperactivity |
| Speech | Slow, monotonous | Normal or pressured |
| Reflexes | Hyporeflexia; delayed relaxation of deep tendon reflexes (ankle jerk) - hallmark sign | Hyperreflexia |
| Tremor | None | Fine postural tremor of hands (most evident in hands, but can occur elsewhere) |
| Peripheral nerves | Peripheral neuropathy, paresthesias | Mild peripheral neuropathy |
| Seizures | Rare (in myxedema crisis) | Rare; embolic stroke from AF |
| Myopathy | Slow movements; pseudomyotonia | Proximal weakness |
LOWER LIMBS / PERIPHERAL
| Finding | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Ankle jerks | Delayed relaxation phase (at least 2x the contraction phase) - classic sign | Brisk / hyperreflexia |
| Edema | Non-pitting myxedema at ankles | Pretibial myxedema (Graves); peripheral edema from CHF |
| Temperature | Cool peripheries | Warm peripheries |
KEY DISTINGUISHING FEATURES AT A GLANCE
| Feature | Hypothyroidism | Hyperthyroidism |
|---|---|---|
| Temperature tolerance | Cold intolerance | Heat intolerance |
| Metabolism | Slow (weight ↑, fatigue, constipation) | Fast (weight ↓, diarrhea, sweating) |
| Heart | Slow (bradycardia, low output) | Fast (tachycardia, AF, high output) |
| CNS | Slow (lethargy, delayed reflexes) | Hyperactive (tremor, brisk reflexes) |
| Skin | Cold, dry, rough | Warm, moist, smooth |
| Hair | Coarse, brittle | Fine, silky, thin |
| Unique signs | Loss of outer eyebrow, macroglossia, delayed ankle jerk, myxedema | Exophthalmos, pretibial myxedema, thyroid acropachy, Plummer's nails (all mainly Graves) |
Sources: - Tintinalli's Emergency Medicine, p. 1489 | - Tietz Textbook of Laboratory Medicine (7th ed.), p. 2320-2322 | - Andrews' Diseases of the Skin (Dermatology), p. 582 | - Tietz Box 57.4 and Box 57.5
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