History
Generally, when diffuse toxic goiter is suspected, a constellation of information, including the extent and duration of symptoms, past medical history, and social and family history, in addition to the information derived from physical examination, help to guide the clinician to the appropriate diagnosis. Graves disease is an autoimmune disease, and patients often have a family history or past medical history of autoimmune disease (eg, rheumatoid arthritis, vitiligo, pernicious anemia).
Patients with Graves disease often have more marked symptoms than patients with thyrotoxicosis from other causes, because thyroid hormone levels usually are the highest with this form of hyperthyroidism. The diagnosis of Graves disease should also be considered if any evidence of thyroid eye disease exists, including periorbital edema, diplopia, or proptosis.
Many symptoms are adrenergic in origin and may be misdiagnosed as an anxiety disorder. Common symptoms of thyrotoxicosis include the following:
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Nervousness
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Anxiety
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Increased perspiration
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Heat intolerance
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Hyperactivity
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Palpitations
Physical Examination
Graves disease is characterized by the stigmata of diffuse toxic goiter, oculopathy, and pretibial myxedema/acropachy. General physical examination findings may include:
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Tachycardia or atrial arrhythmia
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Systolic hypertension with wide pulse pressure
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Warm, moist, smooth skin
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Lid lag
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Stare
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Hand tremor
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Muscle weakness
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Weight loss despite increased appetite (although a few patients may gain weight, if excessive intake outstrips weight loss)
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Reduction in menstrual flow or oligomenorrhea
Thyroid examination
Thyroid size, tenderness, symmetry, and nodularity should also be assessed. Diffuse toxic goiter findings include a mildly enlarged thyroid gland (but may be normal in size, many times normal in size, or difficult to palpate) with a smooth, rubbery firm texture. It is nontender or mildly tender. Sometimes, a thyroid bruit can be heard by using the bell of the stethoscope.
Toxic multinodular goiters generally occur when the thyroid gland is enlarged to at least double to triple the normal size. The gland is often soft, but individual nodules occasionally can be palpated.
If the thyroid is enlarged and painful, subacute painful or granulomatous thyroiditis is the likely diagnosis. However, degeneration or hemorrhage into a nodule and suppurative thyroiditis should also be considered.
Ophthalmologic and dermatologic examination
Thyroid ophthalmopathy is present in 20-25% of cases and may be manifested only by periorbital edema, but it also can include conjunctival edema (chemosis), injection, poor lid closure, extraocular muscle dysfunction (diplopia), and proptosis. Evidence of thyroid eye disease and high thyroid hormone levels confirms the diagnosis of autoimmune Grave disease.
Thyroid dermopathy occurs rarely. Pretibial myxedema lesions are bilateral, firm, nonpitting, asymmetrical plaques or nodules. Hair follicles are sometimes prominent, giving a peau d'orange texture. Areas of nonpitting edema may develop. Thyroid acropachy may be present (which mimics the appearance of clubbing). Most patients who develop pretibial myxedema and acropachy have associated Graves ophthalmopathy. The onset of dermopathy typically follows the onset of ophthalmopathy by 6-12 months.
