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OVERVIEW
This page is dedicated to organizing various examples of standardized exam questions whose answer is Graves disease. While this may seem a odd practice, it is useful to see multiple examples of how Graves disease will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a traditional question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a disease is quite valuable.
KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)
When it comes to standardized exams, each condition has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for Graves disease.
Chief Complaints:
- Symptoms of hyperthyroidism: heat intolerance, sweating , palpitations, weight loss
- Eye manifestations: blurry vision, double vision, painful eye movements, eye irritation (from proptosis/exophthalmos)
Clinical Workup:
- Diffuse goiter can be seen on exam
- Hand tremors may be present (seen in hyperthyroidism)
- Hyperreflexia may be present (seen in hyperthyroidism)
- Proptosis/exophthalmos: bulging eyes characteristic (VERY specific for this condition)
- Pretibial myxedema: thickened and indurated skin in the pretibial area (specific for this condition)
- Low TSH: supressed in this condition
- High T3/T4: increased in this condition
- Homogenous iodine uptake seen on a thyroid scan.
QUESTION EXAMPLES
Question # 1
55-year-old female comes to the clinic because she has painful eye movements, double vision, and eye irritation. Over the last few weeks, she has also experienced weight loss and feels tired. The patient smokes a pack of cigarettes a day and has a 30 pack your history. Past medical history is notable for COPD. She has suffered a head injury in a traffic collision about five months ago. Her blood pressure is 145/75 mm Hg, pass is 110/min, and respirations are 20/min. The physical exam is notable for the patient’s inability to maintain eye convergence and double vision on upward gaze. The eyes are shown in the image below.
What is the likely diagnosis in this patient?
Explanation # 1
Eye symptoms (double vision etc) + hyperthyroidism symptoms (weight loss) + proptosis/exophthalmos) = Graves disease
Question # 2
A 30 year old woman presents to the ER with complaints of eye irritation and double vision. She also explains that recently she has lost weight, has heart palpitations, and also has felt her mood has been erratic. Currently her blood pressure is 145/70 mm Hg and her push is 111 bpm.. A physical exam is notable for bilateral eye redness and marked proptosis. What is the likely diagnosis in this patient?
Question # 2
Eye symptoms (double vision, etc) + hyperthyroidism symptoms (weight loss, etc) + proptosis/exophthalmos = Graves disease
Question # 3
A 34 year old woman comes to the clinic because she has been experiencing mood swings, heart palpitations, heavy sweating, and also feels tired during the day. She has become frustrated with these symptoms and is curious as to what is causing them. A physical exam reveals that she has notable exophthalmos, and also has fine tremors in her hands. What is the likely diagnosis?
Question # 3
Hyperthyroidism symptoms (heart palpitations, etc) + hand tremors + proptosis/exophthalmos = Graves disease
Question # 4
A 45 year old male has come to the clinic because he has had trouble sleeping, feels fatigued, and has noticed recent heart palpitations. He also explains that he has lost about 18lbs over the past 6 months despite eating regularly, and has noticed that he has bee sweating profusely at work. He explains that he can not think of any reasons fo this insomnia. A physical exam reveals thickening of the skin on the lower legs, and associated induration. His past medical history is unremarkable, and he denies smoking tobacco or drinking alcohol. Initial lab results reveal an elevated serum free thyroxine, and TSH levels are low. What is the likely diagnosis in this patient?
Question # 4
Hyperthyroidism symptoms (heart palpitations, etc) + pretibial myxedema + increased serum free thyroxine + low TSH = Graves disease
Question # 5
A 24 year old woman presents with complaints of nervousness and mood swings. Her pulse is 112 bpm, and her blood pressure is 140/75 mm Hg. She appears to have a wide-eyed starting gaze. The fingers on her hand have a fine tremor when they are extended. A physical exam also reveals a diffusely enlarged thyroid gland. What is the likely diagnosis in this patient?
Question # 5
Proptosis/exophthalmos + finger tremor + goiter = Graves disease
Question # 6
A 70 year old female comes to the clinic after 3 months of experiencing sweating, heat intolerance, and heart palpitations. The patient also explains that she has lost a large amount of weight even though she has been eating more recently. Her past medical history is notable for hypertension that is controlled with a calcium channel blocker. Her blood pressure is 120/85 mm Hg, and her pulse is 115 bpm. A physical exam reveals a non-tender diffuse mass on the front of her neck that moves up when the patient drinks and swallows water. Fine tremors and hyperreflexia are noted on the physical exam. Labs are conducted and reveal low levels of TSH an elevated level of T3 and T4. A radioactive iodine uptake study is conducted, and at 24 hours shows that there is significant increased signal evenly distributed throughout the thyroid. What is the likely diagnosis in this patient?
Question # 6
Hyperthyroidism symptoms (heart palpitations, etc) + goiter + tremors/hyperreflexia + low TSH + high T3/T4 + increased uniform uptake of iodine in thyroid = Graves disease
Question # 7
A 45 year old female come sot the clinic because she has been experiencing heart palpitations and anxiety for the past 2 months. She also explains that she has lost 10 lbs during this time period. She has a past medical history that is unremarkable. Her blood pressure is 150/80 mm Hg and her pulse is 115 bpm. A physical exam reveals exophthalmos. Her thyroid gland is also large and non-tender. Serum studies are performed and show a TSH levels < 0.1 µU/mL and a T4 level of 18 µg/dL. A thyroid scan is performed and shows diffuse increased uptake throughout the gland. What is the likely diagnosis in this patient?
Question # 7
Hyperthyroidism symptoms (heart palpitations, etc) + proptosis/exophthalmos + goiter + low TSH + high T4 + increased uniform uptake of iodine in thyroid = Graves disease
TESTABLE FACTS ABOUT THIS CONDITION (BEYOND ITS IDENTIFICATION)
Many questions on standardized exams go beyond simply recognizing the underlying condition. Often there are specific testable facts regarding some aspect of the disease’s pathophysiology/management/clincial implications that are commonly asked. Some of these are listed below:
Cause:
- Autoantibodies that stimulate the TSH receptor (thyrotropin receptor).
Management:
- Conservative (pregnant patients, elderly, those without severe disease burden): antithyroid drugs (propylthiouracil, methimazole)
- Agressive (significant symptoms, very high thyroid levels): radioactive iodine or thyroidectomy. Often pre-treatment with antithyroid drugs is used before radioactive iodine to tone down the transient hyperthyroidism that insures with this treatment.
- Beta adrenergic-blocking medications (propranolol) is also often given to control symptoms caused by increased beta adrenergic signaling (sweating, hypertension, tachycardia)
- High dose steroids (prednisone) are used to control severe Graves opthalmopathy (decrease inflammation).
Complications:
- Thionamide-induced agranulocytosis can be caused by certain antithyroid medications (propylthiouracil, methimazole). Consider getting a CBC in a patient who has Graves and present with a sore throat and fever!
Page Updated: 01.31.2017