History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include iodine deficiency, age >40 years, and head and neck irradiation.
goitre
Usually irregular rather than smooth in texture.
Substernal extension may occur.
Absence of palpable goitre does not rule out toxic multinodular goitre.
Other diagnostic factors
common
heat intolerance, hyperphagia, or weight loss
May be present in overt hyperthyroidism, particularly in younger patients.
Weight loss alone may occur in older patients with apathetic hyperthyroidism.
depression
Depression or other mood change may be seen alone in apathetic hyperthyroidism.
nervousness or palpitations
Palpitations may suggest a dysrhythmia such as atrial fibrillation.
oligomenorrhoea
Relevant to premenopausal women.
hyperdefecation
Less common in older than younger people.
stare or lid lag
May be present when hyperthyroidism is overt.
Stigmata of Graves' disease (exophthalmos and pretibial myxoedema) are absent.
warm, moist skin
May be present when hyperthyroidism is overt.
tachycardia
Less common in older than in younger people.
irregular pulse
May indicate atrial fibrillation.
tremor
Typically fine resting tremor.
uncommon
muscle weakness
May be proximal.
shortness of breath or choking sensation
May occur with large goitre.
Pemberton's sign
Extension of arms over the head results in jugular venous distension and facial plethora due to thoracic inlet obstruction.[24]
Risk factors
strong
iodine deficiency
Worldwide, iodine deficiency is the most common cause of nodular goitre.[12] Iodine Global Network: Global scorecard of iodine nutrition in 2021 in the general population based on school-age children (SAC) Opens in new window In iodine-deficient areas (e.g., regions of Europe, Southeast Asia, and Africa) toxic adenomas and toxic multinodular goitres are more common causes of hyperthyroidism than Graves' disease.[3][5]
Iodine supplementation of salt and other foods has made nodular goitres and toxic nodules less common in many countries.[13]
age >40 years
Toxic multinodular goitre is more common in older patients.
head and neck irradiation
Most commonly received as treatment for lymphomas.
Accidental exposure to radiation may also be a risk factor.
weak
family history of thyroid nodules
Development of nodular disease is influenced by environmental factors interacting with genetic background, sex, and age.[12] Rarely, germline mutations in the thyrotropin receptor gene may also cause non-autoimmune autosomal dominant toxic multinodular goitre.
female sex
Nodular thyroid disease is more common in women, although the underlying mechanisms are not well understood.[12]
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