If there is no orbital involvement, a workup to determine the cause of the hyperthyroidism is indicated. Dyspnea and palpitations are common, and older patients may present with only these complaints, making the diagnosis more difficult. The physical exam may reveal tremor, anxiety, palmar erythema, brisk reflexes, and tachycardia. The patient's thyroid gland is usually diffusely enlarged and nontender. A bruit may be heard over the gland because of increased blood flow.
Cardiac manifestations can include tachycardia and atrial arrhythmias such as atrial fibrillation.
The classic eye findings were present in the patient in case 1, but are not found in most patients who have Graves' disease. Ophthalmologic manifestations vary and can be classified as noninfiltrative and infiltrative. Lid lag and widened palpebral fissures are attributed to noninfiltrative sympathetic stimulation of the levator muscle of the upper eyelid. Exophthalmos results from pressure buildup behind the globe. The increased pressure is due to infiltration of the orbital tissues, especially the extraocular muscles, and from edema caused by the immunologic reaction.