Toxic multinodular goiter physical examination

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

Overview

Physical Examination

Appearance of the Patient

  • Patients with thyroid adenoma are usually well-appearing.
  • Tachycardia may be present.

Skin

  • Flushing
  • Diaphoresis
  • Smooth skin
  • Onycholysis and nail softening
  • Hyperpigmentation
  • Thinning of the hair

Neck

HEENT

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

Lungs

  • Shortness of breath on exertion
  • Hypoxemia
  • Hypercapnia
  • Tracheal compression from a large goiter.
  • Pulmonary hypertension.

Heart

  • Tachycardia with wide pulse pressure.
  • Systolic hypertension
  • Congestive heart failure
  • Dilated cardiomyopathy
  • Atrial fibrillation

Abdomen

  • Weight loss
  • Increased appetite
  • Anorexia in older hyperthyroid patients.
  • Dysphagia
  • Cholestiatosis

Genitourinary

  • Urinary frequency and nocturia are common in hyperthyroidism.
  • Enuresis is common in children.
  • Serum sex hormone-binding globulin (SHBG) concentrations are high.
  • Extragonadal conversion of testosterone to estradiol is increased, so that serum estradiol concentrations are high. These changes can cause gynecomastia, reduced libido, and erectile dysfunction.
  • Spermatogenesis is often decreased or abnormal.

Neuromuscular

  • psychosis, agitation, and depression.
  • anxiety, restlessness, irritability, and emotional lability.
  • Insomnia is also common.cognitive impairments confusion, poor orientation and immediate recall, amnesia, and constructional difficulties.
  • Peripheral neuropathy A symmetric distal sensory disturbance and reduced Achilles reflexes are the most common features. Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy have also been described in patients with hyperthyroidism, probably reflecting an underlying predisposition to autoimmune disease.
  • Carpal tunnel syndrome

Extremities

  • Tremor is common in patients with thyrotoxicosis. The tremor is kinetic, high frequency and low amplitude and can involve the face and head as well as the extremities.
  • Myopathy 
  • Muscle weakness with or without atrophy and myalgias occurs in 60 to 80 percent of patients with untreated hyperthyroidism. Acute thyrotoxic myopathy may present with more severe proximal and distal weakness. muscle atrophy is usually absent. However. Deep tendon reflexes are usually normal or increased, Paresthesias, due to coexisting polyneuropathy may be present.

Bone

  • Bone resorption due to increased bone turn over
  • The loss in cortical bone density is greater than that of trabecular bone.
  • Osteoporosis and an increased fracture

References

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