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


==Overview==
==Overview==
*
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]].
 
==Physical Examination==
==Physical Examination==
===Appearance of the Patient===
===Appearance of the Patient===


*Patients with thyroid adenoma are usually well-appearing.
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>
*Vital Signs
 
*[[Tachycardia]] may be present.
*Patients with [[thyroid adenoma]] are usually well-appearing.


=== Skin ===
=== Skin ===
* Flushing of skin
* [[Flushing]]
* [[Diaphoresis|Increased sweating]]
* [[Diaphoresis]]
* Smooth skin because of a decrease in the keratin layer
* Smooth skin  
* Onycholysis (loosening of the nails from the nail bed, Plummer's nails) and softening of the nails
* [[Onycholysis]] and nail softening
* Hyperpigmentation: it is mediated by accelerated cortisol metabolism and increased corticotropin secretion
* [[Hyperpigmentation]]
* Thinning of the hair
* Thinning of the hair


=== Neck ===
=== Neck ===
* [[Thyromegaly]] with solitary, non-tender thyroid nodules.
* [[Thyromegaly]] with solitary, non-tender thyroid nodules.
* The nodules may be soft, smooth, and mobile. The mass moves with deglutition.
* Soft, smooth, and mobile nodules.
* [[Lymphadenopathy]]
* [[Lymphadenopathy]]


===HEENT===
===HEENT===
*Lid lag occurs in all patients with hyperthyroidism due to sympathetic overactivity.  
*Lid lag occurs in all patients with [[hyperthyroidism]] due to sympathetic overactivity.  


===Lungs===
===Lungs===
* Dyspnea on exertion
* [[Shortness of breath]] on exertion
* Hypoxemia and hypercapnia
* [[Hypoxemia]]
* Tracheal obstruction from a large goiter.
* [[Hypercapnia]]
* Pulmonary hypertension.  
* [[Tracheal compression]] from a large [[goiter]].
* [[Pulmonary hypertension]].


===Heart===
===Heart===
* Heart rate is increased with wide pulse pressure.
* [[Tachycardia]] with [[wide pulse pressure]].
* Systolic hypertension, congestive heart failure, and dilated cardiomyopathy can occur in patients with severe hyperthyroidism.
* [[Systolic hypertension]]
* Atrial fibrillation occurs in patients with hyperthyroidism
* [[Congestive heart failure]]
* In 60% of hyperthyroid patients with atrial fibrillation, the rhythm converts spontaneously to sinus rhythm when the hyperthyroidism is treated.
* [[Dilated cardiomyopathy]]
* [[Atrial fibrillation]]


===Abdomen===
===Abdomen===
*Weight loss is due to increased metabolic rate
*[[Weight loss]]
*Most patients have hyperphagia
*[[Increased appetite]]
*Anorexia may be prominent in older hyperthyroid patients.
*[[Anorexia]] in older hyperthyroid patients.
*Dysphagia due to goiter
*[[Dysphagia]]
*Cholestiatosis


===Genitourinary===
===Genitourinary===
*Urinary frequency and nocturia are common in hyperthyroidism.
*Increased urinary frequency and [[nocturia]]
*Enuresis is common in children.
*[[Enuresis]] is common in children.
*Serum sex hormone-binding globulin (SHBG) concentrations are high.
*[[Gynecomastia]]
*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.
*[[Reduced libido]]
*Spermatogenesis is often decreased or abnormal.
*[[Erectile dysfunction]].


===Neuromuscular===
===Neuromuscular===
*psychosis, agitation, and depression.  
*[[Psychosis]], [[agitation]], and [[depression]].  
*anxiety, restlessness, irritability, and emotional lability.  
*[[Anxiety]], [[restlessness]], [[irritability]], and [[Emotional lability|emotional lability.]]
*Insomnia is also common.cognitive impairments confusion, poor orientation and immediate recall, amnesia, and constructional difficulties.
*[[Insomnia]]
*'''Peripheral neuropathy'''  A symmetric distal sensory disturbance and reduced Achilles reflexes are the most common features [23,86-88].  Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy have also been described in patients with hyperthyroidism, probably reflecting an underlying predisposition to autoimmune disease.
*[[Cognitive impairment|Cognitive impairments]] such as [[confusion]], poor orientation and immediate recall, [[amnesia]], and constructional difficulties.
*Carpal tunnel syndrome  
*[[Peripheral neuropathy]]
*[[Carpal tunnel syndrome]]


===Extremities===
===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.
* High and low frequency amplitude [[tremors]] which can involve the face and head as well as the extremities.
* Myopathy 
* [[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.
* Muscle [[weakness]] with or without [[atrophy]] and [[myalgias]].
* Proximal and distal [[weakness]].
* [[Deep tendon reflex|Deep tendon reflexes]] are usually normal or increased,   
* [[Paresthesias]], due to coexisting [[polyneuropathy]]


=== Bone ===
=== 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
*Osteoporosis and an increased fracture


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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