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__NOTOC__
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{{Toxic multinodular goiter}}
{{Toxic multinodular goiter}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}}{{Ajay}}  


==Overview==
==Overview==
*Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
The clinical features of toxic multinodular goiter includes [[flushing]], [[diaphoresis]], smooth skin, [[onycholysis]], [[hyperpigmentation]], thinning of the hair, [[thyromegaly]],[[lymphadenopathy]], lid lag, [[Dyspnea on exertion|shortness of breath on exertion]], [[hypoxemia]], [[hypercapnia]], [[tachycardia]], [[atrial fibrillation]], [[weight loss]], [[increased appetite]], [[anorexia]], [[dysphagia]], [[increased urinary frequency]], [[enuresis]], [[gynecomastia]], [[reduced libido]], [[erectile dysfunction]], [[psychosis]], [[agitation]], and [[depression]], [[anxiety]], [[restlessness]], [[irritability]], and [[emotional lability]]. Some other features which may be seen are [[insomnia]], [[confusion]], poor orientation and immediate recall, [[amnesia]], and constructional difficulties, [[peripheral neuropathy]], [[carpal tunnel syndrome]], [[tremors]].
*Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
==Physical Examination==
==Physical Examination==
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].
===Vital Signs===
*High-grade / low-grade fever
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
Physical examination is as follows:<ref name="pmid3970328">{{cite journal |vauthors=Katlic MR, Grillo HC, Wang CA |title=Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital |journal=Am. J. Surg. |volume=149 |issue=2 |pages=283–7 |year=1985 |pmid=3970328 |doi= |url=}}</ref><ref name="pmid3885887">{{cite journal |vauthors=Katlic MR, Wang CA, Grillo HC |title=Substernal goiter |journal=Ann. Thorac. Surg. |volume=39 |issue=4 |pages=391–9 |year=1985 |pmid=3885887 |doi= |url=}}</ref><ref name="pmid6648812">{{cite journal |vauthors=Allo MD, Thompson NW |title=Rationale for the operative management of substernal goiters |journal=Surgery |volume=94 |issue=6 |pages=969–77 |year=1983 |pmid=6648812 |doi= |url=}}</ref><ref name="pmid6648812">{{cite journal |vauthors=Allo MD, Thompson NW |title=Rationale for the operative management of substernal goiters |journal=Surgery |volume=94 |issue=6 |pages=969–77 |year=1983 |pmid=6648812 |doi= |url=}}</ref><ref name="pmid7661484">{{cite journal |vauthors=Torre G, Borgonovo G, Amato A, Arezzo A, Ansaldo G, De Negri A, Ughè M, Mattioli F |title=Surgical management of substernal goiter: analysis of 237 patients |journal=Am Surg |volume=61 |issue=9 |pages=826–31 |year=1995 |pmid=7661484 |doi= |url=}}</ref><ref name="pmid6831895">{{cite journal |vauthors=Torres A, Arroyo J, Kastanos N, Estopá R, Rabaseda J, Agustí-Vidal A |title=Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter |journal=Crit. Care Med. |volume=11 |issue=4 |pages=265–6 |year=1983 |pmid=6831895 |doi= |url=}}</ref><ref name="pmid11074902">{{cite journal |vauthors=Marqusee E, Benson CB, Frates MC, Doubilet PM, Larsen PR, Cibas ES, Mandel SJ |title=Usefulness of ultrasonography in the management of nodular thyroid disease |journal=Ann. Intern. Med. |volume=133 |issue=9 |pages=696–700 |year=2000 |pmid=11074902 |doi= |url=}}</ref><ref name="pmid11444166">{{cite journal |vauthors=Hegedüs L |title=Thyroid ultrasound |journal=Endocrinol. Metab. Clin. North Am. |volume=30 |issue=2 |pages=339–60, viii–ix |year=2001 |pmid=11444166 |doi= |url=}}</ref><ref name="pmid6648812">{{cite journal |vauthors=Allo MD, Thompson NW |title=Rationale for the operative management of substernal goiters |journal=Surgery |volume=94 |issue=6 |pages=969–77 |year=1983 |pmid=6648812 |doi= |url=}}</ref><ref name="pmid7661484">{{cite journal |vauthors=Torre G, Borgonovo G, Amato A, Arezzo A, Ansaldo G, De Negri A, Ughè M, Mattioli F |title=Surgical management of substernal goiter: analysis of 237 patients |journal=Am Surg |volume=61 |issue=9 |pages=826–31 |year=1995 |pmid=7661484 |doi= |url=}}</ref><ref name="pmid6831895">{{cite journal |vauthors=Torres A, Arroyo J, Kastanos N, Estopá R, Rabaseda J, Agustí-Vidal A |title=Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter |journal=Crit. Care Med. |volume=11 |issue=4 |pages=265–6 |year=1983 |pmid=6831895 |doi= |url=}}</ref><ref name="pmid22147633">{{cite journal |vauthors=Banks CA, Ayers CM, Hornig JD, Lentsch EJ, Day TA, Nguyen SA, Gillespie MB |title=Thyroid disease and compressive symptoms |journal=Laryngoscope |volume=122 |issue=1 |pages=13–6 |year=2012 |pmid=22147633 |doi=10.1002/lary.22366 |url=}}</ref>
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises


<gallery widths=150px>
*Patients with [[thyroid adenoma]] are usually well-appearing.


UploadedImage-01.jpg | Description {{dermref}}
=== Skin ===
UploadedImage-02.jpg | Description {{dermref}}
* [[Flushing]]
* [[Diaphoresis]]
* Smooth skin
* [[Onycholysis]] and nail softening
* [[Hyperpigmentation]]
* Thinning of the hair


</gallery>
=== Neck ===
* [[Thyromegaly]] with solitary, non-tender thyroid nodules.
* Soft, smooth, and mobile nodules.
* [[Lymphadenopathy]]


===HEENT===
===HEENT===
* Abnormalities of the head/hair may include ___
*Lid lag occurs in all patients with [[hyperthyroidism]] due to sympathetic overactivity.  
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]  
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
 
===Neck===
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Asymmetric chest expansion / Decreased chest expansion
* [[Shortness of breath]] on exertion
*Lungs are hypo/hyperresonant
* [[Hypoxemia]]
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
* [[Hypercapnia]]
*Rhonchi
* [[Tracheal compression]] from a large [[goiter]].
*Vesicular breath sounds / Distant breath sounds
* [[Pulmonary hypertension]].
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
===Heart===
*Chest tenderness upon palpation
* [[Tachycardia]] with [[wide pulse pressure]].
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
* [[Systolic hypertension]]
*[[Heave]] / [[thrill]]
* [[Congestive heart failure]]
*[[Friction rub]]
* [[Dilated cardiomyopathy]]  
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
* [[Atrial fibrillation]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope


===Abdomen===
===Abdomen===
*[[Abdominal distention]]  
*[[Weight loss]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Increased appetite]]
*[[Rebound tenderness]] (positive Blumberg sign)
*[[Anorexia]] in older hyperthyroid patients.
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*[[Dysphagia]]
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Genitourinary===
*A pelvic/adnexal mass may be palpated
*Increased urinary frequency and [[nocturia]]
*Inflamed mucosa
*[[Enuresis]] is common in children.
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
*[[Gynecomastia]]
*[[Reduced libido]]
*[[Erectile dysfunction]].


===Neuromuscular===
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
*[[Psychosis]], [[agitation]], and [[depression]].  
* Altered mental status
*[[Anxiety]], [[restlessness]], [[irritability]], and [[Emotional lability|emotional lability.]]
* Glasgow coma scale is ___ / 15
*[[Insomnia]]
* Clonus may be present
*[[Cognitive impairment|Cognitive impairments]] such as [[confusion]], poor orientation and immediate recall, [[amnesia]], and constructional difficulties.
* Hyperreflexia / hyporeflexia / areflexia
*[[Peripheral neuropathy]]
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
*[[Carpal tunnel syndrome]]
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Extremities===
*[[Clubbing]]  
* High and low frequency amplitude [[tremors]] which can involve the face and head as well as the extremities.
*[[Cyanosis]]  
* [[Myopathy]] 
*Pitting/non-pitting [[edema]] of the upper/lower extremities
* Muscle [[weakness]] with or without [[atrophy]] and [[myalgias]].
*Muscle atrophy
* Proximal and distal [[weakness]].
*Fasciculations in the upper/lower extremity
* [[Deep tendon reflex|Deep tendon reflexes]] are usually normal or increased, 
* [[Paresthesias]], due to coexisting [[polyneuropathy]]
 
=== Bone ===
*Osteoporosis and an increased fracture


==References==
==References==

Latest revision as of 15:06, 13 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ajay Gade MD[2]]

Overview

The clinical features of toxic multinodular goiter includes flushing, diaphoresis, smooth skin, onycholysis, hyperpigmentation, thinning of the hair, thyromegaly,lymphadenopathy, lid lag, shortness of breath on exertion, hypoxemia, hypercapnia, tachycardia, atrial fibrillation, weight loss, increased appetite, anorexia, dysphagia, increased urinary frequency, enuresis, gynecomastia, reduced libido, erectile dysfunction, psychosis, agitation, and depression, anxiety, restlessness, irritability, and emotional lability. Some other features which may be seen are insomnia, confusion, poor orientation and immediate recall, amnesia, and constructional difficulties, peripheral neuropathy, carpal tunnel syndrome, tremors.

Physical Examination

Appearance of the Patient

Physical examination is as follows:[1][2][3][3][4][5][6][7][3][4][5][8]

Skin

Neck

HEENT

  • Lid lag occurs in all patients with hyperthyroidism due to sympathetic overactivity.

Lungs

Heart

Abdomen

Genitourinary

Neuromuscular

Extremities

Bone

  • Osteoporosis and an increased fracture

References

  1. ↑ Katlic MR, Grillo HC, Wang CA (1985). "Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital". Am. J. Surg. 149 (2): 283–7. PMID 3970328.
  2. ↑ Katlic MR, Wang CA, Grillo HC (1985). "Substernal goiter". Ann. Thorac. Surg. 39 (4): 391–9. PMID 3885887.
  3. ↑ 3.0 3.1 3.2 Allo MD, Thompson NW (1983). "Rationale for the operative management of substernal goiters". Surgery. 94 (6): 969–77. PMID 6648812.
  4. ↑ 4.0 4.1 Torre G, Borgonovo G, Amato A, Arezzo A, Ansaldo G, De Negri A, Ughè M, Mattioli F (1995). "Surgical management of substernal goiter: analysis of 237 patients". Am Surg. 61 (9): 826–31. PMID 7661484.
  5. ↑ 5.0 5.1 Torres A, Arroyo J, Kastanos N, Estopá R, Rabaseda J, Agustí-Vidal A (1983). "Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter". Crit. Care Med. 11 (4): 265–6. PMID 6831895.
  6. ↑ Marqusee E, Benson CB, Frates MC, Doubilet PM, Larsen PR, Cibas ES, Mandel SJ (2000). "Usefulness of ultrasonography in the management of nodular thyroid disease". Ann. Intern. Med. 133 (9): 696–700. PMID 11074902.
  7. ↑ Hegedüs L (2001). "Thyroid ultrasound". Endocrinol. Metab. Clin. North Am. 30 (2): 339–60, viii–ix. PMID 11444166.
  8. ↑ Banks CA, Ayers CM, Hornig JD, Lentsch EJ, Day TA, Nguyen SA, Gillespie MB (2012). "Thyroid disease and compressive symptoms". Laryngoscope. 122 (1): 13–6. doi:10.1002/lary.22366. PMID 22147633.

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