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:

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

• Thyromegaly with solitary, non-tender thyroid nodules.
• Soft, smooth, and mobile nodules.
• Lymphadenopathy

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

• Increased urinary frequency and nocturia
• Enuresis is common in children.
• Gynecomastia
• Reduced libido
• Erectile dysfunction.

Neuromuscular

• Psychosis, agitation, and depression.
• Anxiety, restlessness, irritability, and emotional lability.
• Insomnia
• Cognitive impairments such as confusion, poor orientation and immediate recall, amnesia, and constructional difficulties.
• Peripheral neuropathy
• 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