Diseases » Goiter » Diagnosis

Diagnosis of Goiter

Goiter Diagnosis: Book Excerpts

• Ask the following questions - EXOPHTHALMOS
• Ask the Following Questions - THYROID ENLARGEMENT
• Differential Diagnosis - Proptosis/Exophthalmos
• Differential Diagnosis - Proptosis/Exophthalmos
• Differential Diagnosis - Salivary Gland Enlargement
• Approach to the Diagnosis - EXOPHTHALMOS
• History and physical examination - Exophthalmos
• History and physical examination - Thyroid enlargement
• Diagnosis - Exophthalmos
• Diagnosis - Simple goiter
• History and physical examination - Thyroid enlargement
• History and physical examination - Exophthalmos [Proptosis]
• History - Thyroid Enlargement/Goiter
• History - Thyroid Nodule
• Differential Overview - Thyroid Nodule
• Differential Overview - Neck Mass/Thyroid Enlargement
• Differential Overview - Exophthalmos
• Differential Overview - Papules/Nodules
• Diagnosis - Goiter
• History - Exophthalmos
• History - Thyroid enlargement
• Clinical Features and Diagnosis - Scrotal Enlargement
• Clinical Features and Diagnosis - Parotid Gland Enlargement
• History and physical examination - Thyroid enlargement
• History and physical examination - Exophthalmos [Proptosis]
• Approach to the Diagnosis - EXOPHTHALMOS

Diagnostic Tests for Goiter: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Goiter.

EXOPHTHALMOS: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it bilateral or unilateral? Bilateral exophthalmos would suggest hyperthyroidism. Unilateral exophthalmos suggests orbital tumor, abscess, or aneurysm.
2. If it is bilateral, are there signs of hyperthyroidism? If there are other indications of hyperthyroidism, Graves' disease would be the diagnosis.
3. If it is unilateral, does the eyeball pulsate? A pulsating eyeball would suggest an arteriovenous fistula, and there should be a loud blowing murmur over the orbit.
4. Is there fever? Fever would suggest acute cellulitis, acute sinusitis, periostitis, or a cavernous sinus thrombosis.
5. Is there chemosis or ecchymosis? These signs are suggestive of a cavernous sinus thrombosis.

DIAGNOSTIC WORKUP

In cases of bilateral exophthalmos, particularly if there is no fever or chemosis or ecchymosis, a thyroid profile is the most valuable test. Orbital MRI may also be done. However, Graves' disease may be present with normal thyroid function tests. Testing for thyrotropin receptor antibody and peroxidase antibodies should be done in these cases. Other endocrine studies may be necessary once hyperthyroidism has been excluded. In cases of unilateral exophthalmos, ultrasonography and plain films of the orbits and sinuses may be helpful, but a CT scan of the brain and sinuses is the most valuable diagnostic aid. Carotid angiography will need to be done to diagnose an arteriovenous fistula.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

THYROID ENLARGEMENT: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it focal or diffuse? Focal masses in the thyroid include thyroglossal cyst, toxic adenoma, colloid cyst, Riedel's struma, nontoxic adenoma, and malignancies.
2. Is there movement with protrusion of the tongue? This is a typical finding in cases of thyroglossal cyst.
3. If focal, are there signs of thyrotoxicosis? The presence of thyrotoxicosis and a focal mass suggest toxic adenoma.
4. If diffuse, are there signs of thyrotoxicosis? Diffuse thyroid enlargement with thyrotoxicosis indicates Graves' disease.
5. 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

Proptosis/Exophthalmos: Differential Diagnosis
(In a Page: Signs and Symptoms)

• TAO
  –Major cause of unilateral and bilateral proptosis
  –Usually bilateral, although often asymmetric
  –Course is variable
  –Associated with Graves’ disease; more commonly occurs in women, smokers, and in patients treated with radioactive iodine
• Orbital cellulitis
  –Most cases occur due to contiguous spread from sinusitis
• Mucormycosis
  –Occurs primarily in diabetic and immunocompromised patients
  • Orbital tumors
    –Children: Dermoid, capillary hemangioma, rhabdomyosarcoma, lymphangioma, optic nerve glioma, leukemia (chloroma or granulocytic sarcoma), metastatic neuroblastoma, plexiform neurofibroma, teratoma
    –Adults: Metastatic breast, lung, or prostate cancer; cavernous hemangioma; mucocele; lymphoid tumors; optic nerve sheath meningioma; neurofibroma; neurilemoma (schwannoma); fibrous histiocytoma; hemangiopericytoma
  • Trauma (e.g., intraorbital foreign body, retrobulbar hemorrhage)
  • Orbital vasculitis (e.g., Wegener's granulomatosis, polyarteritis nodosa)
  • Arteriovenous malformation (e.g., carotid-cavernous fistula, retina or brain)
  • Cavernous sinus thrombosis
    –Orbital cellulitis signs plus cranial neuropathies (third, fourth, fifth, and/or sixth)
    –Mental status changes
    –Usually bilateral and rapidly progressive
  • Neurofibromatosis
  • Pseudoproptosis
    –Enlarged globe (myopia, buphthalmos)
    –Enophthalmos of the fellow eye

  Workup and Diagnosis

  • History and physical examination
    –History should include age, tempo of onset, pain, fever, laterality, diplopia, thyroid disease, sinusitis, or trauma; history of diabetes, immunosuppression, or cancer; and maneuvers or conditions that worsen proptosis
    –Physical exam should include ophthalmologic, head and neck, and focal neurologic examinations
    –Measure proptosis with exophthalmometer
  • Initial laboratory evaluation may include thyroid function tests (TSH, free T₄ and T₃, TSH receptor antibodies), ESR, CRP, CBC
  • Consider ANCA, ANA, and blood cultures
  • CT and/or MRI of orbits
  • Ultrasound (with color Doppler for suspected arteriovenous malformation)
  • Consider ophthalmology, neurosurgical, and/or endocrine consultation
  • Consider biopsy of selected solid tumors

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Source: In a Page: Signs and Symptoms, 2004

Proptosis/Exophthalmos: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Orbital cellulitis is associated with ethmoid sinusitis, presents with rapid onset of fever, EOM restriction, periorbital edema

• Malignancy
  –Rhabdomyosarcoma: Most common primary pediatric orbital malignancy, average age 5–7, proptosis is presenting sign, may develop acutely
  –Neuroblastoma: One of most common childhood cancers, most frequent source of orbital metastasis, associated with opsoclonus (rapid multidirectional eye movements), periorbital ecchymoses, 40% bilateral
  –Acute leukemia: Most common childhood malignancy, may cause proptosis, ecchymosis, and lid edema

• Benign tumors
  –Capillary hemangioma: Most common benign pediatric orbital tumor, females > males, presents in infancy, slowly progressive, increases in size with crying, associated with skin hemangioma, thrombocytopenic purpura
  –Lymphangioma: Second most common benign pediatric orbital tumor consists of lymph-filled channels, may hemorrhage after minor trauma or URI (chocolate cyst)

• Neurofibromatosis type 1 (NF1)
  –Optic gliomas: Slowly progressive, associated with decreased vision, optic disc atrophy, and swelling
  –Orbital and periorbital plexiform neurofibromas; associated with sphenoid bone defects, may be pulsatile

• Hyperthyroidism
  –Graves disease is the cause of hyperthyroidism most commonly associated with proptosis/exophthalmos
  –Proptosis may be unilateral or bilateral, and lid retraction is common

• Trauma
  –Fracture of orbital bones and hemorrhage into the orbital space may cause proptosis, pain, and EOM impairment
• Orbital dermoid cyst
  –Rupture of cyst causes an inflammatory reaction
• Craniosynostosis (e.g., Apert, Crouzon)

Workup and Diagnosis

• History
  –Onset, duration, progression, pain
  –Other ocular symptoms such as vision loss, diploplia
  –Systemic symptoms such as fever, fatigue
  –Associated symptoms such as skin rash, birthmarks (e.g., café au lait spots in NF1), tremors, palpitations
  –History of trauma
  –Past medical history of CA, thyroid disease, neurocutaneous disorders

• Physical exam
  –Temperature, vital signs, growth parameters
  –Doppler studies to evaluate orbital blood flow
  –Check vision and visual fields
  –Evaluate pupil function and EOM movement (pain, diplopia, restriction)
  –Palpate orbital rim for mass
  –Funduscopic exam including optic nerve and retinal appearance
  –Physical examination for skin findings, abdominal mass, hepatomegaly, neurological exam

• Labs
  –TSH, T3, T4
  –CBC, ESR, LDH, blood cultures
• Studies
  –CT or MRI to look for masses
  –Doppler studies to evaluate orbital blood flow
• Biopsy if diagnosis uncertain

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Salivary Gland Enlargement: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Congenital
  –First branchial cleft cyst
  –Retention cyst
  –Ectopic rests of salivary tissue
• Infectious/inflammatory
  –Mumps (before immunization) was the most common salivary gland inflammatory disease
  –HIV
  –Coxsackie A
  –Echovirus
  –Viral sialoadenitis
  –Acute bacterial sialoadenitis: Typically Staphylococcus aureus or Streptococcus viridans
  –Sialolithiasis
  • Vascular lesions
    –Hemangiomas: Most common salivary gland mass in children
    –Lymphangioma
  • Benign tumors
    –Pleomorphic adenomas: Most common solid benign tumor
    –Warthin tumors
    –Oncocytoma
    –Adenomas
  • Malignant tumors
    –Mucoepidermoid carcinoma: Most common
    –Acinic cell carcinoma
    –Adenoid cystic carcinoma
    –Undifferentiated carcinoma
    –Lymphoma
    –Rhabdomyosarcoma
    –Squamous cell carcinoma
  • Trauma (may often be associated with facial nerve injury)
  • Systemic diseases
    –Diffuse bilateral salivary gland enlargement: often associated with diabetes mellitus, cystic fibrosis, thyroid disease, malnutrition, obesity, autoimmune disorders (Sjögren)
    –Granulomatous disease: tuberculosis, atypical Mycobacterium, sarcoidosis, cat-scratch disease
    • Drugs such as methimazole, thiourea, phenothiazine, thiocyanate

    Workup and Diagnosis

    • History
      –Duration, onset, pain, change in size with meals, prior history of recent weight loss or gain, joint tenderness
      –Past medical history of systemic disease: CF, diabetes, autoimmune disorders
      –Exposure: Immunization, radiation, cat-scratch disease
    • Physical exam
      –Size, character: Firm, soft, cystic, tenderness, warmth, redness, bilaterality, oral cavity exam, pus from Stenson or Wharton duct, palpable stone, neck mass, facial nerve function (paresis or paralysis is highly suggestive of malignancy)
    • Culture of drainage may guide antibiotic therapy
    • Plain film X-rays: Limited utility but may identify salivary duct stone; 80–90% of submandibular stones are radio-opaque
    • Ultrasound: May differentiate between cystic and solid lesions, ductal dilations, and intra- and extraparenchymal lesions
    • CT or MRI: Provides better resolution of salivary gland lesions and surrounding tissues; MRI gives superior details for salivary gland neoplasms
    • Fine-needle aspiration: 90% sensitivity and 95–100% specificity for identifying malignancy with experienced pathologist
    • Sialography: Limited in children, contraindicated in acute infections

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Source: In A Page: Pediatric Signs and Symptoms, 2007

EXOPHTHALMOS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Because bilateral exophthalmos is usually due to hyperthyroidism, a thyroid profile must be done. The most useful in this profile are the total T4 level by immunoassay, the free thyroxine index, and the RAI uptake and scan. A total T3 by immunoassay should be done to exclude T3 thyrotoxicosis. Because bilateral exophthalmos can occur without hyperthyroidism, testing for thyrotropin receptor antibody and peroxidase antibodies must be done if thyroid function tests are negative. With exophthalmos, chemosis, and ecchymosis, the patient should be hospitalized for a workup of cavernous sinus thrombosis and a neurologist consulted. When there is unilateral exophthalmos, ultrasonography and angiography will rule out carotid–cavernous fistula and a cystic lesion. A CT scan of the brain and orbits will rule out tumors and abscess. It is wise to consult a neurologist, ophthalmologist, or endocrinologist to assist in this workup.

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Source: Differential Diagnosis in Primary Care, 2007

Exophthalmos: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin by asking when the patient first noticed exophthalmos. Is it associated with pain in or around the eye? If so, ask him how severe it is and how long he has had it. Then ask about recent sinus infection or vision problems. Take the patient's vital signs, noting a fever, which may accompany eye infection. Next, evaluate the severity of exophthalmos with an exophthalmometer. (See Detecting unilateral exophthalmos.) If the eyes bulge severely, look for cloudiness on the cornea, which may indicate ulcer formation. Describe any eye discharge and observe for ptosis. Then check visual acuity, with and without correction, and evaluate extraocular movements. Palpate the patient's thyroid for enlargement or goiter.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

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.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Exophthalmos: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Exophthalmos is usually obvious on physical examination; exophthalmometer readings confirm diagnosis by showing the degree of anterior projection and asymmetry between the eyes (normal bar readings range from 12 to 20 mm). The following diagnostic measures identify the cause:

❑ Computed tomography scan or magnetic resonance imaging detects swollen extraocular muscles or lesions within the orbit.

❑ Culture of discharge determines the infecting organism; sensitivity testing indicates appropriate antibiotic therapy.

❑ Biopsy of orbital tissue may be necessary if initial treatment fails.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Simple goiter: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis of simple goiter requires a thorough patient history and physical examination to rule out disorders with similar clinical effects, such as Graves’disease, Hashimoto’s thyroiditis, and thyroid carcinoma. A detailed patient history may also reveal goitrogenic medications or foods or endemic influence. The results of diagnostic laboratory tests include the following:

❑ TSH: high or normal levels

❑ Serum T₄ concentrations: low normal or normal

❑ Thyroid scan and uptake: normal or increased (50% of the dose at 24 hours)

❑ Ultrasound of thyroid: nodules may be present, necessitating biopsy for further evaluation.

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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.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Exophthalmos [Proptosis]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin by asking when the patient first noticed exophthalmos. Is it associated with pain in or around the eye? If so, ask him how severe it is and how long he has had it. Then ask about recent sinus infection or vision problems. Take the patient’s vital signs, noting fever, which may accompany an eye infection. Next, evaluate the severity of exophthalmos with an exophthalmometer. (See Detecting unilateral exophthalmos.) If the eyes bulge severely, look for cloudiness on the cornea, which may indicate ulcer formation. Describe any eye discharge and observe for ptosis. Then check visual acuity, with and without correction, and evaluate extraocular movements. Palpate the patient’s thyroid for enlargement or goiter.

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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).

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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.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

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.

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Source: Field Guide to Bedside Diagnosis, 2007

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Exophthalmos: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Grave disease

❑ Familial

❑ Orbital asymmetry

❑ Orbital cellulitis

❑ Cavernous sinus thrombosis

❑ Orbital hemorrhage/emphysema

❑ Intracavernous carotid artery aneurysm

❑ Arteriovenous fistula

❑ Carotid-cavernous sinus fistula

❑ Orbital tumor

❑ Pituitary apoplexy

❑ Meningioma

Diagnostic Approach

The patient may present with exposure keratitis, resulting from an inability to close the eyelid fully, or with diplopia resulting from unilaterally impaired extraocular movement. By standing behind the patient, tilting the head back, and viewing down the brow ridge, as little as 2 mm of eye protrusion can be detected.

Unilateral pulsating proptosis can be caused by an AV fistula between the internal carotid and the cavernous sinus in a basilar skull fracture, by an aneurysm of the ophthalmic artery, or by a rapidly enlarging and highly vascular orbital neoplasm. These vascular lesions produce a pulsating tinnitus and a dimming of vision.

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Source: Field Guide to Bedside Diagnosis, 2007

Papules/Nodules: Differential Overview
(Field Guide to Bedside Diagnosis)

Pigmented

❑ Nevus

❑ Seborrheic keratosis

❑ Atypical nevus

❑ Melanoma

Colored

❑ Cherry angioma

❑ Basal cell carcinoma

❑ Erythema nodosum

❑ Lichen planus

❑ Xanthoma

❑ Kaposi sarcoma

❑ Sarcoidosis

❑ Blue nevus

❑ Amyloidosis

❑ Lymphoma cutis

❑ Polyarteritis nodosa

❑ Bacillary angiomatosis

❑ Sweet syndrome

❑ Bowen disease

❑ Cutaneous tuberculosis

Non-pigmented

❑ Epidermoid inclusion cyst

❑ Lipoma

❑ Acrochordon

❑ Dermatofibroma

❑ Ganglion cyst

❑ Wart

❑ Molluscum contagiosum

❑ Milia

❑ Rheumatoid nodule

❑ Tophus

❑ Squamous cell carcinoma

❑ Keratoacanthoma

❑ Neurofibroma

❑ Neuroma

❑ Cutaneous metastasis

❑ Calcinosis cutis

❑ Adenoma sebaceum

Diagnostic Approach

Violaceous papules and plaques occur in cutaneous sarcoidosis, lymphocytoma cutis, and cutaneous lupus.

Findings useful in differentiating atypical from benign nevi are as follows:

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Source: Field Guide to Bedside Diagnosis, 2007

Goiter: Diagnosis
(Handbook of Diseases)

An accurate diagnosis of simple goiter requires a thorough patient history and physical examination to rule out disorders with similar clinical effects, such as Graves’disease, Hashimoto’s thyroiditis, and thyroid carcinoma. A detailed patient history also may reveal goitrogenic medications or foods or endemic influence.

The results of diagnostic laboratory tests include the following:

❑ TSH — high or normal

❑ serum T₄ concentrations — low normal or normal

❑ iodine 131 uptake — normal or increased (50% of the dose at 24 hours).

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Exophthalmos: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin by asking when the patient first noticed exophthalmos. Is it associated with pain in or around the eye? If so, ask him how severe the pain is and how long he has had it. Then ask about recent sinus infection or vision problems.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

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

Scrotal Enlargement: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Painful Scrotal Enlargement

Testicular

Torsion of Testis

Twistingof spermatic cord causes diminished blood flow to testis and acutescrotal pain. Lower abdominal pain and vomiting also may occur.Tender, swollen testis is located higher in scrotum, and cremastericreflex is usually absent.

History of intermittent bouts of scrotalpain may indicate previous intermittent torsion.

In many cases, diagnosis can be madeclinically and should be confirmed by prompt surgical exploration.If diagnosis is uncertain, procedure of choice to determine testicularperfusion is U/S with color flow Doppler.

Orchitis

May existas isolated viral infection (mumps virus is most common) or as extension ofepididymitis.

Unusual before puberty.

1 or both testes are swollen and painful.

With mumps infection, orchitis usuallyoccurs a few days after onset of parotitis.

Trauma

Trauma toscrotum may produce a spectrum of disease, including mild swelling,hematoma formation, or rupture of testis with blood in scrotum.

U/S is procedure of choiceto assess structural integrity of scrotum.

Nontesticular

Torsion of Appendages of Testis and Epididymis

Attachedto the testis and epididymis are vestiges of embryologic remnantsthat can twist around their base, producing infarction. This iscalled torsion of appendix testis or appendix epididymis.

Usual age of occurrence is school agebefore adolescence. Pain is usually not as severe as with torsionof testis and develops over a few days. Tender bluish nodule signifyingtorsion of appendix testis is often seen at superior lateral aspectof testis. Torsion of appendix epididymis occurs at head of epididymis.

This is often clinical diagnosis; however,scrotal U/S should be performed if diagnosis is uncertain.

Epididymitis

Most commonin adolescents who are sexually active, whereas younger boys tendto have associated urinary tract infection.

Scrotal pain and swelling as well asepididymal tenderness are usual findings. Early in illness, it maybe possible to distinguish epididymis from testis, but this maybe impossible with progression of inflammation and swelling.

If diagnosis is uncertain, scrotalU/S with color flow Doppler can be performed. UA and urineculture also should be performed.

After course of appropriate treatmentin older age group, if dysfunctional voiding exists, urinary urodynamictesting should be performed. In younger age group after course ofappropriate treatment, renal U/S and contrast voiding cystourethrographyshould be performed, because urinary tract anomalies (e.g., posteriorurethral valves or ectopic ureter emptying into seminal vesicle)may occur.

Incarcerated Inguinal Hernia

Painful,tender mass is palpable in inguinal area with extension at timesinto scrotum.

If hernia cannot be reduced, compromiseof bowel may occur, and surgery should be performed immediately.If hernia can be reduced, surgery is usually performed in a fewdays, after swelling has decreased.

Nonpainful Scrotal Enlargement

Testicular

In Utero Torsion

Poor fixationof spermatic cord during fetal life predisposes to in utero torsionof testis during testicular descent.

Firm testicular mass is discolored,and salvage of infarcted testis is unlikely.

Although some controversy exists aboutmanagement, exploration and contralateral orchiopexy are performedelectively in our hospital once infant is stable.

Tumor

Testiculartumors are rare in children and usually present as painless, firmto hard, testicular masses. Most common ones include yolk sac tumor,teratoma, and testis infiltration with leukemia or non-Hodgkin lymphoma.

Scrotal U/S can confirm presenceof testicular tumor. Histologic diagnosis is definitive.

Nontesticular

Inguinal Hernia

May extend into scrotum and produce enlargedscrotum. Increased intraabdominal pressure with crying or strainingmay produce recurrent episodes of painless inguinal and scrotalswelling. Although reduction is usually easy, hernia should be repairedto prevent incarceration.

Hydrocele

Fluid withintunica vaginalis surrounding testis is called a hydrocele. Becausepatent processus vaginalis permits communication with abdominalcavity, hydrocele may change in size because of changing amountof fluid in scrotum.

Communicating hydrocele tends to persistand may lead to development of inguinal hernia if diameter of processusbecomes larger. Closed processus results in formation of noncommunicatinghydrocele. Its size does not fluctuate, and fluid often disappearsby 1 yr of age.

Hydrocele of spermatic cord may presentas fluid-filled inguinal canal mass.

Occasionally, hydrocele may occur inolder children secondary to trauma, inflammation, or testiculartumor.

U/S is helpful if diagnosisis uncertain.

Spermatocele

Is a sperm-containing cyst of rete testes,ductuli efferentes, or epididymis. It is nontender, usually <1cm in diameter, and located posterior and superior to testis inpostpubertal boys. Aspiration yields milky fluid composed of spermcells. Surgery may be required if cyst is painful.

Varicocele

Group ofdilated, elongated spermatic cord veins, which may be seen in boys10–15 yrs of age. Most varicoceles occur on left side.

Scrotum is enlarged and sometimes painful.Mass is often described as bag of worms. Veins are palpable on standingbut collapse and disappear in supine position. Valsalva maneuveror coughing also may cause varicocele to become more apparent.

Presence of testicular atrophy on affectedside is indication for surgery because of possible occurrence ofinfertility.

Henoch-Schönlein Purpura

Purpuric rash in this disorder typicallyoccurs on buttocks and lower legs. Occasionally, rash may involvescrotum and cause some swelling. See Chap.28, Hematuria.

Kawasaki Disease

Scrotal swelling also may occur with Kawasakidisease, which is discussed in Chap.21, Fever.

Meconium Peritonitis

Intestinalperforation is cause of antenatal meconium peritonitis. Meconiumpasses along patent processus vaginalis into scrotum, and bilateralneonatal hydroceles may be palpable as firm nodular masses on 1or both sides of scrotum.

Abdominal radiography that includesscrotum demonstrates calcifications in scrotum as well as underdiaphragm. U/S also may confirm diagnosis.

Tumors of Epididymis, Spermatic Cord, or Scrotal Wall

Benign tumorsinclude lipoma, fibroma, leiomyoma, and lymphangioma. Paratesticularrhabdomyosarcoma is of most concern.

U/S can help locate and defineextent of tumor.

Histologic diagnosis is definitive.

Generalized Edema

Scrotal edema may occur as part of generalizededema, which is discussed in Chap.17, Edema. Testis and spermatic cord are normal.

Diagnostic Approach

Cause ofscrotal enlargement often can be determined clinically based onhistory and physical exam. Age of child, type of presentation (acuteor chronic, unilateral or bilateral), and presence of scrotal ortesticular pain or testicular enlargement are distinguishing featuresuseful in diagnosis.

Torsion of testis, torsion of appendixtestis, and epididymitis often can be distinguished clinically earlyin clinical course. With progression of disease process, this maynot be possible. If diagnosis is uncertain, U/S with colorflow Doppler should be performed. Surgical exploration is indicatedwhenever there is high suspicion of torsion of testis.

Transillumination can help distinguishsolid or cystic lesions, but incarcerated inguinal hernia also cantransilluminate.

U/S can determine whethermass is testicular or nontesticular and can distinguish solid from cysticlesions.

Nontesticular cystic lesions are usuallybenign and can be managed according to specific diagnosis. Testicularmass is assumed to be malignant tumor until proven otherwise.

>

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Parotid Gland Enlargement: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Infection/Inflammation

Viral Infection

Most commoncause of parotid gland enlargement is viral infection, usually with mumpsvirus.

In mumps parotitis, 1 or both parotidglands are enlarged, tender, and painful. Fever is variable finding.Inflamed ductal punctum with clear saliva suggests viral infection.

Other viruses that may be associatedwith parotitis include enteroviruses, parainfluenza viruses, influenzaviruses, Epstein-Barr virus, cytomegalovirus, lymphocytic choriomeningitisvirus, and HIV.

Positive viral culture of oropharynxis diagnostic.

Bacterial Infection

Bacterialinfection of parotid gland is more unusual than viral infection.Common pathogens are S. aureus and viridans streptococci. Infectionswith S. pneumoniae, E. coli, P. aeruginosa, M. catarrhalis, andanaerobes are less common.

Usual clinical findings are fever andpainful, tender, swollen gland. If purulent material oozes fromparotid duct, Gram stain and bacterial culture should be performed.

U/S or CT can detect parotidabscess, and needle aspiration may yield culture-positive material.

Parotid duct stones and stricturespredispose to bacterial infection.

Recurrent Parotitis of Childhood

Characterizedby recurrent swelling of parotid gland occurring every few monthsand sometimes associated with fever. Pathogenesis is unknown, butillness does respond to antibiotics.

Between episodes, the child is asymptomatic.

Diagnosis is confirmed by history,physical exam, clinical course, response to antimicrobials, andtests to determine presence of any stone or mass.

Parotid Gland Obstruction

Calculus,food particle, or stricture may cause obstruction of parotid ductwith subsequent enlargement of the gland.

Increased pain and gland enlargementwith eating suggest a lesion obstructing salivary flow. Palpationmay reveal duct stone.

If a stone is not visible on plainradiograph, CT may be useful in diagnosis.

Allergic Reaction

Rare cause of parotid enlargement that usuallyproduces acute, nonpainful, bilateral swelling, which lasts hoursto several days. Presence of other allergic manifestations (e.g.,urticaria or wheezing) and predominance of eosinophils in parotidduct secretions supports diagnosis.

Trauma

Direct traumato the face may injure parotid gland or duct.

Dental appliances or chronic cheekchewing may produce chronic irritation and inflammation of punctumwith resulting stricture formation and infection.

History and physical exam are usuallydiagnostic.

Masses

Cysts

Parotidcysts are usually nontender unless they are infected.

Some cysts are congenital, whereasothers occur secondary to parotid duct obstruction caused by trauma,infection, stricture, or calculi.

U/S can distinguish cysticfrom solid masses.

Neoplasm

Most tumorsof parotid gland in pediatric population are benign. They includehemangioma (most common), lymphangioma, and pleomorphic adenoma.Tumors are usually single, mobile, firm, and slow growing.

Malignant tumors include various carcinomasand sarcomas but are rare. Malignancy should be suspected if massis hard, fixed, and rapidly enlarging. Parotid gland is also commonsite for metastases from tumors of scalp, face, cheek, orbit, andexternal nose.

CT and MRI are useful in defining extentof mass and in surgical planning. Histologic diagnosis is definitive.

Sjögren Syndrome

In thischronic autoimmune disorder, parotid gland enlargement may be unilateralor bilateral. Other findings are dry eyes (keratoconjunctivitissicca), dry mouth (xerostomia), and arthritis.

Lab findings include increased serumimmunoglobulin G, positive rheumatoid factor, and antibodies toRo (SS-A) and La (SS-B).

Biopsy of minor salivary glands oflower lip that shows lymphocytic infiltration confirms diagnosis.

Sarcoidosis

One manifestation of sarcoidosis is uveoparotidfever, in which there is bilateral, tender enlargement of parotidgland, uveitis, and fever. See Chap.38, Lymphadenopathy, for further discussion ofsarcoidosis.

Drugs

Iodide-containing compounds may produce parotidenlargement, but mechanism is unknown.

Diagnostic Approach

In manycases of parotid enlargement, history and physical exam are diagnostic.

Most common cause of parotid enlargementin children is viral infection.

Presence of fever, gland fluctuance,and pus from parotid duct indicates presence of bacterial infection,and positive bacterial culture is diagnostic.

History usually provides clues to trauma,allergic reaction, and use of iodine-containing compounds.

U/S can distinguish cysticand solid masses. Although CT and MRI locate and define extent ofneoplastic lesions, histologic diagnosis is definitive.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

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

Exophthalmos [Proptosis]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin by asking when the patient first noticed exophthalmos. Is it associated with pain in or around the eye? If so, ask him how severe it is and how long he has had it. Then ask about recent sinus infection or vision problems. Take the patient's vital signs, noting a fever, which may accompany eye infection. Next, evaluate the severity of exophthalmos with an exophthalmometer. (See Detecting unilateral exophthalmos.) If the eyes bulge severely, look for cloudiness on the cornea, which may indicate ulcer formation. Describe any eye discharge and observe for ptosis. Then check visual acuity, with and without correction, and evaluate extraocular movements. Palpate the patient's thyroid for enlargement or goiter.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

EXOPHTHALMOS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Because bilateral exophthalmos is usually due to hyperthyroidism, a thyroid profile must be done. The most useful in this profile are the total T₄ level by immunoassay, the free thyroxine index, and the radioiodine (RAI) uptake and scan. A total triiodothyronine (T₃) test by immunoassay should be done to exclude T₃ thyrotoxicosis. Because bilateral exophthalmos can occur without hyperthyroidism, testing for thyrotropin receptor antibody and peroxidase antibodies must be done if thyroid function tests are negative. With exophthalmos, chemosis, and ecchymosis, the patient should be hospitalized for a workup of cavernous sinus thrombosis and a neurologist consulted. When there is unilateral exophthalmos, ultrasonography and angiography will rule out carotid–cavernous fistula and a cystic lesion. A CT scan of the brain and orbits will rule out tumors and abscesses. It is wise to consult a neurologist, ophthalmologist, or endocrinologist to assist in this workup.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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