HISTORY 1. Age of the patient is a very important consideration. Simple goiter is commonly seen in girls approaching puberty. In endemic areas deficient iodide is the cause of the simple goiter in teen-aged girls. Where hormone production is not very much below the normal level, simple Goitrogens and dyshormonogenesis are also the causes of simple goiter. These are mainly found hormone is augmented. Both multinodular and solitary nodular goiters as well as colloid goiters goiter may appear in conditions of need, e.g., puberty and pregnancy when requirement of carcinoma of thyroid is not necessarily a disease of old age. Papillary carcinoma is seen in young are found in women of 20s and 30s. A word of caution is very much in need in this context-girls and follicular carcinoma in middle-aged women. Of course, anaplastic carcinoma is mainly a disease of old age. In case of primary toxic goiter, the patients are usually young, whereas in psychic condition is seen in case of primary thyrotoxicosis, Worry and anxiety are always the Hashimoto's disease the victims are usually middle-aged women. Patients with unbalanced embarrassing features of this condition. 2. Sex: Majority of thyroid disorders are seen in females. All types of simple goiters are far more common in the female than in the male. Thyrotoxicosis is eight times commoner in females in males. Even thyroid carcinomas are more often seen in females in the ratio of 3:1. than 3. Occupation: Though occupation has hardly any relation with thyroid disorders, yet thyrotoxicosis may appear in individuals working under stress and strain. The patients with primary toxic goiter may be psychic. 4. Residence: Except endemic goiter due to iodine deficiency, no other thyroid disorder has any peculiar geographical distribution. Certain areas are particularly known to have low iodine content in the water and food. Residents of these areas often suffer from iodine deficiency endemic simple goiter. These areas are near rocky mountains, e.g., Himalayas, the Vindyas, the Satpuda ranges which form the goiter belts in India. Such goiter is also probably more common in Southern India than in Northern India. In Great Britain such areas are in the Mendips, Derbyshire, Yorkshire, etc. Endemic goiter is also found in low land areas where the soil lacks iodides or the water supply comes from far away mountain ranges, e.g., Great Lakes of North America. In the mountains of Bulgaria arises the river Struma, which flows into the Aegean Sea. Along its banks and those of its tributaries endemic goiter has been prevalent. Calcium is also goitrogenic and areas producing chalk or lime stone are also goitrogenic areas, e.g., Southern Ireland and Derbyshire. 5. Swelling: In case of thyroid swellings history about the onset, duration, rate of growth and whether associated with pain should be noted. In case of any thyroid swelling it should be asked 'how does the patient sleep at night?' 'Does she spend sleepless nights?' In primary thyrotoxicosis patients often complain of sleepless nights. Whether the patient is very worried stressed or strained. These are also features of thyrotoxicosis. Palpitation and ectopic beats These symptoms may develop in already existing thyroid swelling cases for years. In secondary thyrotoxicosis the brunt of the attack falls more on the cardiovascular system, whereas in primary thyrotoxicosis the brunt of attack falls more on the nervous system. Sudden increase in size with pain in a goiter indicates hemorrhage inside it. A thyroglossal cyst may be present since birth. The rate of growth of the swelling is quite important. While simple goiter grows very dowly or may remain of same size for quite sometime, multinodular goiter or solitary nodular goiter or colloid goiter increases in size though extremely slowly for year. These goiters may also increase in size little faster than before. A special feature of papillary and follicular carcinoma of the thyroid is their slow growth. They may exist as a lump in the neck for many year before metastasizing Anaplastic carcinoma however is a fast-growing swelling. painful. Malignant diseases of the thyroid gland are painless to start with, but become painful & Pain: The goiter is usually a painless condition. Inflammatory conditions of thyroid gland are in late stages. In Hashimoto's disease there is discomfort in the neck. Anaplastic carcinoma is more known to infiltrate the surrounding structures and the nerves to cause pain. Pressure effects: Enlarged thyroid may press on the trachea to cause dyspnea or may press on the esophagus to cause dysphagia or press on the recurrent laryngeal nerve to cause hoarseness is a muscular tube and can be easily stretched or pushed aside. As in the first stage of deglutition of the voice. It must be remembered that thyroid swellings can rarely obstruct the esophagus as it the thyroid gland moves up, so an enlarged thyroid gland makes swallowing uncomfortable but usually this is not true dysphagia. An enlarged thyroid may compress on the trachea or deviate neck is flexed forwards or laterally. When air rushes through a narrowed trachea, a whistling it to one side or the other to cause difficulty in breathing. This symptom is often worse when the sound is produced which is called stridor, Hoarseness is usually due to paralysis of one recurrent nerve and anaplastic carcinoma infiltrating the nerve is often the cause. laryngeal 8. Symptoms of primary thyrotoxicosis: It is quite important to know the symptoms of primary thyrotoxicosis as often in these cases there is not much enlargement of the thyroid gland and only these symptoms will indicate the presence of this disease. The most significant symptom is loss of weight inspite of good appetite. Preference for cold and intolerance to heat and excessive sweating are the next symptoms. Nervous excitability, irritability, insomnia, tremor of hands and weakness of muscles are the symptoms of involvement of nervous system which are the main features of primary thyrotoxicosis. Cardiovascular symptoms are not so pronounce as seen in secondary thyrotoxicosis, but even then palpitation, tachycardia (rise in sleeping pulse) and dyspnea on exertion are symptoms of this disease. Exophthalmos is often associated with this condition. The patient may complain of staring or protruding eyes and difficulty in closing her eye lids. Double vision or diplopia may be caused by muscles weakness (ophthalmoplegia). Edema or swelling of the conjunctiva (chemosis) is seen in very late cases of exophthalmos alongwith persistent primary thyrotoxicosis. Ultimately the patient may get pain in the eye if the cornea ulcerates. Some women may have a change in menstruation, usually amenorrhea. 1. Symptoms of secondary thyrotoxicosis: When a longstanding solitary nodular goiter or multinodular goiter or colloid goiter shows manifestations of thyrotoxicosis the condition is called secondary thyrotoxicosis. As mentioned above the brunt of the attack falls more on the cardiovascular system than on the nervous system. Palpitations, ectopic beats, cardiac arrhythmias, dyspnea on exertion and chest pain are the usual symptoms. Even congestive cardiac failure may appear at late stage with swelling of ankles. Nervous symptoms and eye Symptoms may be mild or absent. 2. Symptoms of myxedema (hypothyroidism): Increase of weight is often complained of inspite of poor appetite. Fat accumulates particularly at the back of the neck and shoulder Intolerance of cold weather and preference for warm climate is noticed. There is minimal swelling of thyroid. The skin may be dry. There may be puffiness of the face with pouting lips and dull expression: Loss of hair is a characteristic feature and 2/3rds of the evebrows may fall 売 due to edema of vocal cords CConstipation and oligomenorrhea are sometimes Muscle fatigue and lethargy are important symptoms with failing memory and mild boarseness complained of 11. Past history: Enquiry must be made about the course of treatment the patient had and its effect on the swelling. In case of thyroglossal fistula there may be a previous history of an abscess (an inflamed thyroglossal cyst) which was incised or burst spontaneously. The patient should also be asked if she was taking any drugs, e.g., PAS or sulfonylurea or any antithyroid drugs as these are goitrogenic. 12. Personal history: Dietary habit is important as vegetables of the brassica family (cabbage, kale and rape) are goitrogens. Persons who are in the habit of taking a kind of sea fish which has particularly low iodine content, may present with goiter. 13. Family history: It is often seen that goiters occur in more than one member in a family while endemic goiters may affect more members in the same family. Similarly enzyme deficiency in the synthesis of thyroid hormones seen to run in families. Primary thyrotoxicosis has been seen in more than one member of the same family. Thyroid cancers are seen to involve more than one member of the same family. ☐ A. PHYSICAL EXAMINATION GENERAL SURVEY 1. Build and state of nutrition: In thyrotoxicosis the patient is usually thin and underweight. The patient sweats a lot with wasting of muscles and in hypothyroidism the patient is obese and overweight. In case of carcinoma of thyroid there will be signs of anemia and cachexia. 2. Facies: In thyrotoxicosis one can see the facial expression of excitement, tension, nervousness or agitation with or without variable degree of exophthalmos. In hypothyroidism one can see puffy face without any expression (mask-like face). 3. Mental state and intelligence: Hypothyroid patients are naturally dull with low intelligence. This is more obvious in cretins. 4. Not only the pulse rate becomes rapid, but it becomes irregular in thyrotoxicosis. Irregularity is more of a feature of secondary thyrotoxicosis. Particularly sleeping pulse rate is a very useful index to determine the degree of thyrotoxicosis. In case of mild thyrotoxicosis, it should be below 90, whereas in case of moderate or severe thyrotoxicosis it should be between 90 to 110 and above 110 respectively. In hypothyroidism the pulse becomes slow (bradycardia). 5. Skin: The skin is moist particularly the hands in case of primary thyrotoxicosis. The clinician while feeling for the pulse should take the opportunity to touch the hand as well. Hot and moist palm to come across in primary thyrotoxicosis. Skin is dry and inelastic in myxedema. Simplified