Toxic multinodular goiter physical examination: Difference between revisions
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===Lungs=== | ===Lungs=== | ||
* | * Dyspnea on exertion | ||
* Hypoxemia and hypercapnia[17] | |||
* Tracheal obstruction from a large goiter. 18 | |||
* Pulmonary hypertension. [19] | |||
===Heart=== | ===Heart=== | ||
* Heart rate is increased with wide pulse pressure.5]. | |||
* Systolic hypertension, congestive heart failure, and dilated cardiomyopathy can occur in patients with severe hyperthyroidism.[6] 7 | |||
Systolic hypertension, congestive heart failure, and dilated cardiomyopathy can occur in patients with severe hyperthyroidism.[6] | * Atrial fibrillation occurs in patients with hyperthyroidism 8 | ||
* In 60% of hyperthyroid patients with atrial fibrillation, the rhythm converts spontaneously to sinus rhythm when the hyperthyroidism is treated. [11]. | |||
Atrial fibrillation occurs in patients with hyperthyroidism | |||
In 60 | |||
===Abdomen=== | ===Abdomen=== | ||
* | *Weight loss is due to increased metabolic rate | ||
*Most patients have hyperphagia | |||
*Anorexia may be prominent in older hyperthyroid patients [22]. | |||
*Dysphagia due to goiter | |||
*Cholestiatosis 23 | |||
===Genitourinary=== | ===Genitourinary=== | ||
* | *Urinary frequency and nocturia are common in hyperthyroidism. [31] | ||
*Enuresis is common in children. | |||
*Serum sex hormone-binding globulin (SHBG) concentrations are high [34,35]. | |||
*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 [32,36]. | |||
*Spermatogenesis is often decreased or abnormal [35]. | |||
===Neuromuscular=== | ===Neuromuscular=== | ||
* | *psychosis, agitation, and depression. | ||
*anxiety, restlessness, irritability, and emotional lability [39]. | |||
*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 [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 [90,91]. | |||
*Carpal tunnel syndrome [92] | |||
===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.[23 24 | ||
*'''Myopathy''' | |||
*Muscle weakness with or without atrophy and myalgias occurs in 60 to 80 percent of patients with untreated hyperthyroidism [23,66,67]. Acute thyrotoxic myopathy may present with more severe proximal and distal weakness [74,75]. muscle atrophy is usually absent. However[74,80]. Deep tendon reflexes are usually normal or increased, Paresthesias, due to coexisting polyneuropathy may be present. | |||
=== Bone === | |||
*Bone resorption [37] 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== | ==References== | ||
Revision as of 17:55, 6 October 2017
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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.
- Vital Signs
- Tachycardia may be present.
Skin
- Flushing of skin
- Increased sweating
- Smooth skin because of a decrease in the keratin layer
- Onycholysis (loosening of the nails from the nail bed, Plummer's nails) and softening of the nails
- Hyperpigmentation: it is mediated by accelerated cortisol metabolism and increased corticotropin secretion
- Thinning of the hair
Neck
- Thyromegaly with solitary, non-tender thyroid nodules.[1]
- The nodules may be soft, smooth, and mobile. The mass moves with deglutition.
- Lymphadenopathy
HEENT
- Lid lag occurs in all patients with hyperthyroidism due to sympathetic overactivity. [4]
Lungs
- Dyspnea on exertion
- Hypoxemia and hypercapnia[17]
- Tracheal obstruction from a large goiter. 18
- Pulmonary hypertension. [19]
Heart
- Heart rate is increased with wide pulse pressure.5].
- Systolic hypertension, congestive heart failure, and dilated cardiomyopathy can occur in patients with severe hyperthyroidism.[6] 7
- Atrial fibrillation occurs in patients with hyperthyroidism 8
- In 60% of hyperthyroid patients with atrial fibrillation, the rhythm converts spontaneously to sinus rhythm when the hyperthyroidism is treated. [11].
Abdomen
- Weight loss is due to increased metabolic rate
- Most patients have hyperphagia
- Anorexia may be prominent in older hyperthyroid patients [22].
- Dysphagia due to goiter
- Cholestiatosis 23
Genitourinary
- Urinary frequency and nocturia are common in hyperthyroidism. [31]
- Enuresis is common in children.
- Serum sex hormone-binding globulin (SHBG) concentrations are high [34,35].
- 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 [32,36].
- Spermatogenesis is often decreased or abnormal [35].
Neuromuscular
- psychosis, agitation, and depression.
- anxiety, restlessness, irritability, and emotional lability [39].
- 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 [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 [90,91].
- Carpal tunnel syndrome [92]
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.[23 24
- Myopathy
- Muscle weakness with or without atrophy and myalgias occurs in 60 to 80 percent of patients with untreated hyperthyroidism [23,66,67]. Acute thyrotoxic myopathy may present with more severe proximal and distal weakness [74,75]. muscle atrophy is usually absent. However[74,80]. Deep tendon reflexes are usually normal or increased, Paresthesias, due to coexisting polyneuropathy may be present.
Bone
- Bone resorption [37] due to increased bone turn over
- The loss in cortical bone density is greater than that of trabecular bone.
- Osteoporosis and an increased fracture