In which of the following patients, thyrotoxicosis should not be suspected -
In hyperthyroidism there is proximal muscle weakness. 

Thyrotoxicosis (Hyperthyroidism)

Most common cause of thyrotoxicosis is diffuse hyperplasia of the thyroid, i.e., Graves disease. 

Clinical features

Hyperthyroidism is a hypermetabolic state.
The effects are due to increased level of thyroxin as well as due to overactivity of the sympathetic nervous system.

Features are :

Metabolism → ↑ BMR, Intolerance to heat, weight loss, increased sweating, postprandial hyperglycemia, ↓cholesterol, ↓ phospholipid, ↓ triglyceride, ↑ FFA, Increased appetite.
CVS → ↑ Systolic BP, Hyperdynamic precordium, wide pulse pressure, sinus tachycardia, mid-systolic murmur, Means Lerman scratch, atrial fibrillation, Angina & CHF.
Respiration → ↑ Respiratory rate.
GIT → Diarrhoea
CNS → Nervousness, anxiety
Musculoskeletal system → Proximal muscle weakness, fine tremors, osteoporosis.
Others → Extreme fatiguability but inability to sleep, infertility.


In Graves disease there is exophthalmos, and wide-eyed, Staring gaze.
Patients with unexplained weight loss
Patients with unexplained diarrhoea
Patients with distal muscle weakness
Patients with paroxysmal atrial tachycardia