Confirming diagnosis The following tests confirm the disorder:
❑ Radioimmunoassay shows increased serum T4 and triiodothyronine (T3) concentrations.
❑ Thyroid scan reveals increased uptake of radioactive iodine (131I). This test is contraindicated if the patient is pregnant.
❑ TSH levels are decreased.
❑ Ultrasonography confirms subclinical ophthalmopathy.
❑ Antithyroglobulin antibody is positive in Grave’s 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
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.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Thyrotoxicosis/Hyperthyroidism:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Clinical features. Severity can vary with duration of illness, magnitude of hormone excess, age of the patient, and presence of disease in other organs, such as the heart. Typical patient complaints include thyroid enlargement (depending on cause), dyspnea on exertion, fatigue, proximal muscle weakness (often manifested by difficulty with stair climbing), palpitations, heat intolerance, excessive sweating, tremor, weight loss, nervousness or emotional lability (more common in younger patients), decreased menstrual flow, alterations in appetite, frequent bowel movements, and sleep disturbances (3). A recent viral illness can be an antecedent for subacute thyroiditis.
B. Effect of age. Older patients present with fewer clinical features than younger patients. Tachycardia, fatigue, and weight loss are the only clinical features found in more than 50% of patients aged more than 70 years (4).
Physical examination (PE)
A. Observation. Clothing may be loose because of weight loss. Clothing choices may suggest inappropriate heat intolerance, whereas the welcoming handshake may present warm moist hands with a fine tremor. Other possible observations include nervousness or restlessness, a characteristic stare with widened palpebral fissures, lid lag and infrequent blinking, and silky fine hair.
B. General examination. Vital sign abnormalities commonly include weight loss, sinus tachycardia, arrhythmias, and systolic hypertension with a widened pulse pressure. Systolic murmurs, cardiac enlargement, and, occasionally, overt heart failure may be found on cardiovascular examination (Chapters 7.4, 7.5 and 7.7). Besides the classic stare noted above, Graves’ disease can also present with proptosis (which may be asymmetric), ophthalmoplegia (with impaired conjugate eye movement and strabismus), orbital congestion (with periorbital edema and potential compression of the optic nerve), and inflammation of the conjunctiva and cornea. Pretibial myxedema, an unusual but pathognomonic finding in Graves’disease, is a painless raised thickening of the subcutaneous tissue, most often found in the anterior lower leg or dorsal foot. It produces a peau d’orange texture, which can be pruritic and hyperpigmented. Clubbing of the fingers and toes is also found in Graves’disease, but is very rare. An ovarian mass, usually unilateral, may indicate struma ovarii. Thyrotoxicosis (but not hyperthyroidism) can result from this teratoma, which infrequently produces thyroid hormone.
C. Thyroid examination. Inspect the neck below the thyroid cartilage from the front and side. During palpation, approach the patient from the front or from 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. The size, consistency, and tenderness of the gland are important, as are the presence and characteristics of any nodules. Auscultation of a bruit over the gland correlates with increased vascularity, usually indicative of Graves’disease.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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
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
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.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Thyrotoxicosis:
Diagnosis
(Handbook of Diseases)
The diagnosis of thyrotoxicosis usually is straightforward and depends on a careful clinical history and physical examination, a high index of suspicion, and routine hormone determinations. The following tests confirm the disorder:
❑ Radioimmunoassay shows increased serum thyroxine (T4) and triiodothyronine (T3) concentrations.
❑ Thyroid scan reveals increased uptake of radioactive iodine 131 (131I) in Graves’ disease, and usually in toxic multinodular goiter and toxic adenoma. Radioactive uptake is low in thyroiditis and thyrotoxic factitia. This test is contraindicated if the patient is pregnant.
❑ TSH levels are decreased.
❑ Thyroid-releasing hormone (TRH) stimulation test indicates thyrotoxicosis if the TSH level fails to rise within 30 minutes after the administration of TRH. TRH testing is rarely necessary due to highly sensitive TSH assays.
❑ Ultrasonography confirms subclinical ophthalmopathy.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
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
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
While training for the Olympic games, track star Gail Devers began to suffer from a number of mysterious symptoms: weight loss, dry skin and fatigue....
Hyperthyroidism is a serious hormonal imbalance that most women know little about. It’s caused by an overactivity of the thyroid gland, which...
Hyperthyroidism is a serious hormonal imbalance that can lead to weight loss, anxiety, diarrhea and other symptoms. Treatments are available, and in...
Sleep is necessary to feel refreshed, but now we know sleep actually impacts the way the body functions. Sleeping poorly can affect how often you get...
See full list of 4 related videos
» Next page: Signs of Graves Disease
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
