Key Symptoms to Evaluate in Patients with Suspected Graves' Disease
When evaluating a patient for Graves' disease, clinicians should specifically inquire about heat intolerance, weight loss despite increased appetite, fatigue, tremor, palpitations, anxiety, and sleep disturbances as these are the most common presenting symptoms of thyrotoxicosis. 1, 2, 3
Cardinal Symptoms to Assess
Thyrotoxicosis-Related Symptoms
- Heat intolerance and sweating
- Weight loss despite normal or increased appetite
- Palpitations or awareness of rapid/irregular heartbeat
- Tremor of the hands
- Fatigue and muscle weakness
- Sleep disturbances (particularly insomnia)
- Anxiety, irritability, or mood changes
- Menstrual irregularities in women
Graves'-Specific Symptoms
- Eye symptoms - Ask specifically about:
- Eye pain or pressure
- Gritty sensation in the eyes
- Excessive tearing
- Light sensitivity
- Double vision
- Protruding eyes (proptosis)
- Changes in vision
- Skin changes - Inquire about:
- Thickening of the skin, particularly on the shins (pretibial myxedema)
- Changes in skin texture
- Neck symptoms:
- Neck fullness or tightness
- Difficulty swallowing
- Visible neck enlargement (goiter)
Atypical Presentations to Consider
- Cardiovascular manifestations - Dyspnea, chest pain, or symptoms of heart failure including flash pulmonary edema in severe cases 4
- Apathetic thyrotoxicosis - Particularly in elderly patients who may present with depression, apathy, and weight loss rather than classic hypermetabolic symptoms 1
- Hematological abnormalities - Rarely, patients may present with symptoms related to pancytopenia 5
Focused History Elements
Timing and Progression
- Onset and duration of symptoms
- Pattern of progression (sudden vs. gradual)
- Any precipitating factors (stress, trauma, pregnancy)
Risk Factors and Associated Conditions
- Family history of thyroid or other autoimmune disorders
- Recent stressful life events or psychological trauma 1
- History of other autoimmune conditions
- Radiation exposure to the neck
Medication History
- Use of medications that can affect thyroid function:
- Amiodarone
- Lithium
- Interferon
- Iodine-containing medications or supplements
Clinical Pitfalls to Avoid
Overlooking subtle presentations - Not all patients present with classic symptoms; elderly patients in particular may have "apathetic thyrotoxicosis" 1
Focusing only on thyroid symptoms - Remember to assess for extrathyroidal manifestations that are specific to Graves' disease (ophthalmopathy, dermopathy)
Misattributing symptoms - Anxiety, palpitations, and weight loss may be incorrectly attributed to primary psychiatric disorders
Neglecting to assess severity - Failure to identify symptoms of thyroid storm (fever, extreme tachycardia, altered mental status) which requires emergency treatment
Incomplete medication review - Not asking about supplements, over-the-counter medications, or iodine exposure that can affect thyroid function 6
By systematically evaluating these symptoms, clinicians can more accurately identify patients with Graves' disease and distinguish it from other causes of hyperthyroidism, leading to appropriate diagnostic testing and management.