Graves' disease

An auto-immune condition characterised by thyrotoxicosis and ophthalmopathy, associated with auto-antibodies stimulating the TSH receptor. Diagnosis is often clinical, but the presence of antibodies may help confirm the cause of thyrotoxicosis.

Has the patient lost or gained any weight unintentionally? 

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

Has the patient's appetite increased? 

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

Does the patient complain of diarrhoea or a change in bowel habit? 

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.

Does the patient feel anxious or more irritable than usual? 

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

Has the patient noticed a change in their energy? 

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.

Is the patient sleeping normally or are they more tired than usual? 

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

Does the patient feel hot or flushed?

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.

Has there been a change in menstrual cycle? 

Oligomenorrhoea, scanty periods and amenorrhoea may all occur.

Is there any chance the patient could be pregnant? 

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.

Does the patient feel tremulous or have they developed an overt shake? 

Tremor is common with thyrotoxicosis of any cause.

Has the patient developed any cardiac or respiratory symptoms? 

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.

Does the patient complain of any changes to their skin or hair? 

Increased pigmentation may indicate associated Addison's disease.

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

Has there been any obvious neck swelling or pain? 

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.

Has the patient noticed any changes in their eyes?

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.

Has there been any recent intercurrent illness, for example a viral respiratory tract infection?

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

Is there any family or personal history of thyroid dysfunction, pernicious anaemia, vitiligo, Addison's disease, alopecia, diabetes or coeliac disease?

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

Does the patient smoke?

Smoking increases the risk and severity of ophthalmopathy.