Diagnosis of Autoimmune thyroid diseases
Autoimmune thyroid diseases Diagnosis: Book Excerpts
Diagnostic Tests for Autoimmune thyroid diseases: Online Medical Books
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THYROID ENLARGEMENT:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it focal or diffuse? Focal masses in the thyroid include thyroglossal cyst, toxic adenoma, colloid cyst, Riedel's struma, nontoxic adenoma, and malignancies.
- Is there movement with protrusion of the tongue? This is a typical finding in cases of thyroglossal cyst.
- If focal, are there signs of thyrotoxicosis? The presence of thyrotoxicosis and a focal mass suggest toxic adenoma.
- If diffuse, are there signs of thyrotoxicosis? Diffuse thyroid enlargement with thyrotoxicosis indicates Graves' disease.
- Is it tender? The presence of a tender enlarged thyroid suggests subacute thyroiditis and Hashimoto's thyroiditis.
DIAGNOSTIC WORKUP
Routine tests include a CBC, sedimentation rate, urinalysis, thyroid profile with a TSH immunoassay, chemistry panel, chest x-ray, and EKG. Thyroid antibodies may be tested if Hashimoto's thyroiditis is suspected.
The most important study is a thyroid technetium-99m or iodine-123 uptake and scan. If the results of these are abnormal, then an endocrinologist or general surgeon should be consulted to assist in the interpretation. If the scan indicates a cold nodule, ultrasonography may be done to determine whether the nodule is cystic or solid. If it is cystic, generally it can be aspirated and followed. If it is solid, a biopsy or aspiration and biopsy should be undertaken. If there are malignant cells or at least suspicious cells for malignancy, surgery should be done. If the scan reveals a hot nodule and there is clinical and laboratory evidence of thyrotoxicosis, the patient should be treated with radioactive iodine or surgery. If the scan shows diffuse uptake of radioactive materials and there is clinical thyrotoxicosis, the patient also may be treated with radioactive iodine or surgery.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Thyroid enlargement:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
The patient’s history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, onset of thyroid enlargement, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
Begin the physical examination by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you’ll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient’s neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.
During palpation, be sure to note the size, shape, and consistency of the gland, and the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit. The bruit is often continuous.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Thyroid cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
The first clue to thyroid cancer is usually an enlarged, palpable node in the thyroid gland, neck, lymph nodes of the neck, or vocal cords. A patient history of radiation therapy or a family history of thyroid cancer supports the diagnosis. However, tests must rule out nonmalignant thyroid enlargements, which are much more common. Thyroid scan differentiates between functional nodes (rarely malignant) and hypofunctional nodes (commonly malignant) by measuring how readily nodules trap isotopes compared with the rest of the thyroid gland. In thyroid cancer, the scinti-scan shows a “cold,” nonfunctioning nodule. Other tests include needle biopsy, computed tomography scan, ultrasonic scan, chest X-ray, serum alkaline phosphatase, and serum calcitonin assay to diagnose medullary cancer. Calcitonin assay is a reliable clue to silent medullary carcinoma. (See Staging thyroid cancer.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Thyroiditis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Precise diagnosis depends on the type of thyroiditis:
❑ Autoimmune: high titers of thyroglobulin and microsomal antibodies present in serum
❑ Subacute granulomatous: elevated erythrocyte sedimentation rate, increased thyroid hormone levels, decreased thyroidal radioiodine uptake
❑ Chronic infective and noninfective: varied findings, depending on underlying infection or other disease.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Thyroid enlargement:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
The patient’s history commonly reveals the cause of thyroid enlargement. Important data include a family history of thyroid disease, when the thyroid enlargement began, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
Begin the physical examination by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you’ll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient’s neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.
During palpation, be sure to note the size, shape, and consistency of the gland as well as the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit, which is commonly continuous.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Thyroid Enlargement/Goiter:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
In simple goiter, patients are asymptomatic or, if the gland is sufficiently enlarged, they present with symptoms caused by mechanical pressure. Substernal goiters are frequently responsible for tracheal pressure symptoms, including dyspnea and inspiratory stridor. They can also obstruct the large cervical veins at the thoracic inlet, causing suffusion of the face, giddiness, and syncope (Pemberton’s sign). Esophageal compression can lead to dysphagia (Chapter 9.5). Hoarseness caused by compression of or traction on the recurrent laryngeal nerve is rare in simple goiter and suggests a malignancy (Chapter 6.3). Generalized thyroid pain suggests subacute thyroiditis, whereas sudden localized pain and swelling are consistent with hemorrhage into a nodule. Although simple goiters are usually euthyroid, typical symptoms of hypothyroidism or thyrotoxicosis should be sought. A family history of goiter and a personal history of residing in an endemic goiter area or ingesting goitrogens may be significant (1).
Physical examination
A. General examination. Look for typical vital and physical signs consistent with hypothyroidism or thyrotoxicosis. Pemberton’s sign can be induced by having the patient raise both arms above the head.
B. Thyroid examination. Inspect the neck below the thyroid cartilage from the front, using cross-lighting to accentuate shadows and masses. Full extension of the neck enhances visibility of the gland. Inspection from the side with measurement of any prominence of the normally smooth and straight contour between the cricoid cartilage and the suprasternal notch is useful. Palpitation is done using the technique with which the examiner is most experienced and skilled. Approach the patient from either the front or behind and palpate using the fingers or thumbs. If felt between the cricoid cartilage and the suprasternal notch, the thyroid isthmus can be used to help locate the gland. Palpation of the lobes can be improved by relaxation of the sternocleidomastoid; for example, the left lobe can be defined better by having the patient slightly flex and rotate the neck to the left. Other useful maneuvers include measuring the circumference of the neck or the dimensions of each lobe. Note the location, size, consistency, mobility, and tenderness of any nodules. Having the patient swallow during both inspection and palpation causes the thyroid to move and aids in developing a three-dimensional impression of gland shape and size. This maneuver can also make a low-placed gland accessible. Categorize thyroid size as “normal” or “goiter,” and subcategorize “goiter” as “small” (two or less times normal) or “large” (more than two times normal) (2).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Thyroid Nodule:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Although history is neither sensitive nor specific for diagnosing thyroid cancer, an appropriately focused history can significantly alter the clinical likelihood of malignancy (2).
A. Family history. Approximately 3% of cases of papillary cancer are familial and a high incidence has been reported in patients with adenomatous polyposis coli (Gardner’s syndrome). Medullary cancer often occurs in a hereditary pattern.
B. Personal history. Recent increase in size of a nodule, hoarseness, dysphagia, stridor, or dyspnea can indicate growth or invasiveness and increase the suspicion of cancer. Recurrence of cystic nodules after aspiration is also suggestive of cancer.
1. External beam irradiation before the age of 15 to 20 years, which has been done for conditions such as acne and thymic or tonsillar enlargement, or exposure to ionizing radiation from a nuclear accident, increases the risk of thyroid carcinoma. The risk increases for 15 to 25 years after exposure, remains maximal and stable for 20 years, and then slowly declines.
2. Sudden onset of localized swelling, pain, or tenderness suggests hemorrhage into a preexisting nodule or cyst. Subacute thyroiditis is suggested by fever, a preceding viral illness, and a gradual onset of swelling, pain, and tenderness. Typical symptoms of hypothyroidism suggests Hashimoto’s thyroiditis, whereas thyrotoxicosis suggests toxic adenoma or toxic multinodular goiter (3).
Physical examination
As with the history, physical examination is neither sensitive nor specific for malignancy.
A. General examination. Look for typical vital and physical signs consistent with hypothyroidism or thyrotoxicosis.
B. Thyroid examination. Inspect the neck below the thyroid cartilage from the front and side, using cross-lighting to accentuate shadows and masses. Full extension of the neck enhances visibility of the gland. During palpation, approach the patient from either the front or behind and palpate using the fingers or thumbs. Having the patient swallow during both inspection and palpation causes the thyroid to move and aids in developing a three-dimensional impression of the gland. Note the location, size, consistency, mobility, and tenderness of all nodules. Findings suggestive of cancer include a nodule that is hard, irregular, nontender, greater than 4 cm in size, fixed to surrounding structures or associated with local lymphadenopathy.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Neck Mass/Thyroid Enlargement:
Differential Overview
(Field Guide to Bedside Diagnosis)
Neck Mass
❑ Inflammatory lymphadenopathy
❑ Parotid swelling/tumor
❑ Laryngeal cancer
❑ Intramuscular hematoma
❑ Lymphoma
❑ Nasopharyngeal carcinoma
❑ Branchial cleft cyst
❑ Thyroglossal duct cyst
❑ Supraclavicular adenopathy
❑ Aortic aneurysm
❑ Carotid aneurysm
❑ Ludwig angina
❑ Pharyngeal pouch
❑ Carotid body tumor
Thyroid Enlargement
❑ Simple goiter
❑ Hashimoto thyroiditis
❑ Grave disease
❑ Drugs
❑ Subacute thyroiditis
❑ Thyroid cancer
❑ Infiltrative disease
Diagnostic Approach
Patients often present for evaluation of a “neck mass” that is a normal structure such as the hyoid, and they will insist that it is new or asymmetric.
With thyroid enlargement, the mass will be low in the neck and extend across the midline. Occasionally, a prominent thyroid nodule will mimic a lymph node but is in an atypical location. The thyroid gland rises and falls with swallowing. The only other structure to do this is a thyroglossal duct cyst.
In a multinodular goiter, a malignancy should be suspected when there is a dominant nodule or cervical adenopathy.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Thyroid Nodule:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Hashimoto thyroiditis
❑ Multinodular goiter
❑ Follicular adenoma
❑ Thyroid cyst
❑ Thyroid carcinoma
❑ Subacute thyroiditis
Diagnostic Approach
The major task of physical examination is the detection of nodules. A palpable nodule can be detected in 4% to 7% of adults, but these are present in approximately 50% on ultrasound. The history or physical examination should rarely dissuade one from proceeding to thyroid scan and/or fine needle aspiration.
Approximately 5% of nodules are cancer. High-risk features include: rapid growth, a very firm nodule, fixation, vocal cord paralysis, enlarged regional lymph nodes, distant metastases, and family history of medullary cancer. Moderate risk features are: Age less than 20 years or greater than 60 years, history of neck irradiation (.100 cGy .15 years before), solitary nodule, diameter greater than 4 cm, and questionable fixation.
A thyroid nodule in a hyperthyroid patient is virtually never malignant, but a prominent or hard nodule in a multinodular goiter must be evaluated for cancer.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Chronic fatigue and immune dysfunction syndrome:
Diagnosis
(Handbook of Diseases)
The cause and nature of CFIDS are still unknown, and no single test unequivocally confirms its presence. Therefore, the diagnosis is based on the patient’s history and the CDC criteria. Because the CDC criteria are admittedly a working concept that may not include all forms of this disease and are based on symptoms that can result from other diseases, diagnosis is difficult and uncertain. Considerable overlap exists between CFIDS and fibromyalgia syndrome, with many patients having features of both.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Thyroid cancer:
Diagnosis
(Handbook of Diseases)
The first clue to thyroid cancer is usually an enlarged, palpable node in the thyroid gland, neck, lymph nodes of the neck, or vocal cords. A patient history of radiation therapy or a family history of thyroid cancer supports the diagnosis. However, tests must rule out nonmalignant thyroid enlargements, which are more common.
❑ Fine needle biopsy detects cancer cells.
❑ Thyroid scan differentiates between functional nodes (rarely malignant) and hypofunctional nodes (commonly malignant) by measuring how readily nodules trap isotopes compared with the rest of the thyroid gland. In thyroid cancer, the scintiscan shows a “cold,” nonfunctioning nodule.
❑ Other tests include computed tomography scan, ultrasonic scan, and serum calcitonin assay to diagnose medullary cancer. Calcitonin assay is a reliable clue to silent medullary carcinoma.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Thyroiditis:
Diagnosis
(Handbook of Diseases)
Precise diagnosis depends on the type of thyroiditis:
❑ autoimmune: high titers of thyroglobulin and microsomal antibodies present in serum
❑ subacute granulomatous: elevated erythrocyte sedimentation rate, increased thyroid hormone levels, decreased thyroidal radioactive iodine uptake
❑ chronic infective and noninfective: varied findings, depending on underlying infection or other disease.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Thyroid enlargement:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
The patient’s history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, when the thyroid enlargement began, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Thyroid enlargement:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
The patient's history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, onset of thyroid enlargement, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
Begin the physical examination by inspecting the patient's trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you'll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient's neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.
During palpation, be sure to note the size, shape, and consistency of the gland, and the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit. The bruit is often continuous.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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