Graves' disease

Many patients with hyperthyroidism will lose weight due to increased metabolic rate, though some will gain it due to increased appetite.

Increased appetite with weight loss is a classic presentation of hyperthyroidism.

Increased passage of stools and diarrhoea may occur with any cause of hyperthyroidism. Coeliac disease may also be associated with auto-immune thyroid disease which may also present with a change in bowel habit and weight loss.

Anxiety and irritability are common features of thyrotoxicosis of any cause.

Many patients with hyperthyroidism have an abundance of energy, but complain of an inability to 'switch off'.

Others, particularly older patients, have paradoxically low energy - apathetic thyrotoxicosis.

Many patients with hyperthyroidism will be unable to sleep well as they cannot relax despite feeling physically exhausted.

Heat intolerance is typical with hyperthyroidism.

Premature ovarian failure may also be associated with auto-immune thyroid disease and also presents with oligomenorrhoea and flushes.

Oligomenorrhoea, scanty periods and amenorrhoea may all occur.

The symptoms of thyrotoxicosis may mimic those of pregnancy.

Early foetal loss or miscarriage is more common in women with thyrotoxicosis.

Pregnancy may also cause transient thyrotoxicosis due to stimulation of the TSH receptor by high hCG levels.

Radioactive iodine is absolutely contraindicated in pregnant women.

Tremor is common with thyrotoxicosis of any cause.

Ask whether the patient has palpitations or a feeling of a racing or irregular heart beat, which might suggest tachycardia, atrial fibrillation or another arrhythmia.

Ask whether they have developed chest pain on exertion which might suggest cardiac ischaemia?

Ask about breathlessness or swollen ankles which might suggest thyrotoxic cardiomyopathy, or pulmonary embolism.

Increased pigmentation may indicate associated Addison's disease.

Some patients develop generalised alopecia with thyrotoxicosis though this may also occur in hypothyroidism.

A short history of thyroid swelling should alert to the possibility of thyroid cancer and demands ultra-sound and fine needle aspiration assessment.

Painful diffuse neck swelling is suggestive of thyroiditis. Discomfort from an enlarged gland is more common and may occur with any cause including Graves' disease.

Long standing painless thyroid swelling, with some fluctuation in size is more likely to represent a multinodular goitre. Sudden swelling is most common with a cyst, and sudden painful swelling with bleed into a nodule.

Ask specifically whether their eyes have been feeling gritty or dry, as though there is something stuck in them.

Ask whether they have looked red or puffy at times, or whether their appearance has changed.

Also ask whether they have developed double vision in certain directions or when tired.

Thyroiditis typically follows a viral illness, though this is frequently unrecognised.

Any of these may be associated with auto-immune thyroid dysfunction.

Smoking increases the risk and severity of ophthalmopathy.