Diagnostic Tests for Graves Disease
Graves Disease: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Graves Disease
includes:
Graves Disease Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Graves Disease:
- Thyroid: Home Testing:
- Menopause: Related Home Testing:
- Vaginal Health: Home Testing:
- Adrenal Gland Health: Home Testing:
- Breast Cancer: Related Home Tests:
Graves Disease Diagnosis: Book Excerpts
Tests and diagnosis discussion for Graves Disease:
The only way to positively know if you have Graves' Disease is to visit
your doctor. Your doctor will perform a simple blood test that will be
able to tell if your body has the correct amount of thyroid hormones. (Source: excerpt from Graves' Disease: NWHIC)
Diagnosis of Graves Disease: medical news summaries:
The following medical news items
are relevant to diagnosis of Graves Disease:
Diagnostic Tests for Graves Disease: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Graves Disease.
EXOPHTHALMOS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
THYROID ENLARGEMENT:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
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:
Physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Laboratory testing. A sensitive assay for thyroid-stimulating hormone (sTSH) is the best test for detecting thyrotoxicosis. Thyrotoxicosis from any cause, except the extremely rare instance of excess TSH production, results in a suppressed sTSH. Thyrotoxicosis is confirmed by an elevated free thyroxine index (FTI) or an elevated free thyroxine (fT4), measured directly. If the FTI or fT4 is normal, T3 should be measured to evaluate for T3 toxicosis. Assays for thyroid autoantibodies, including TSH receptor antibodies, are usually not required. However, they can be helpful in selected cases (e.g., pregnancy, where levels correlate with risk to the fetus).
B. Diagnostic imaging. Radioactive iodine uptake (RAIU) can help clarify the cause of thyrotoxicosis. A diffuse increase in RAIU is consistent with Graves’ disease, whereas nodular concentration is consistent with toxic adenoma (a single increased area) or multinodular goiter (multiple areas of increased uptake) (3). A decrease in RAIU is consistent with exogenous (iatrogenic or factitious) thyrotoxicosis, thyroiditis, iodine-induced thyrotoxicosis, or struma ovarii.
Diagnostic assessment
Accurate diagnosis depends on the appropriate combination and interpretation of history, PE, and testing.
A. Graves’ disease. If ophthalmopathy is present, the diagnosis of Graves’ disease is usually obvious. Typically, the thyroid gland is increased in size, smooth, and nontender. A bruit is present in 50% of patients. The RAIU is homogeneously increased and pretibial myxedema may be present.
B. Toxic nodular goiter is the most common cause of thyrotoxicosis in those aged more than 40 years. The thyroid gland is typically increased in size, nontender, but with multiple nodules. The RAIU is increased in a heterogeneous pattern. A single toxic nodule is more common in younger people and has the RAIU concentrated in one spot, with suppression of the remaining gland.
C. Exogenous (iatrogenic or factitious) thyrotoxicosis is associated with a gland that is small or normal sized and a low or absent RAIU. A psychiatric evaluation should be considered in factitious thyrotoxicosis.
D. Thyroiditis. Thyrotoxicosis can be produced as hormone leaks from an inflamed gland. Typically, the symptoms of the diverse thyroiditis entities are of recent onset and have escalated rapidly. The gland is enlarged and either tender (subacute thyroiditis) or nontender (painless thyroiditis or postpartum thyroiditis). RAIU is very low or absent. Transient hypothyroidism often follows as the intrathyroidal stores of hormone are depleted. Acute suppurative thyroiditis is a rare infectious disorder, usually caused by pyogenic organisms (5).
E. Other diagnoses. Thyrotoxicosis with hyperthyroidism and an inappropriately elevated sTSH suggests a TSH-secreting pituitary tumor. Thyrotoxicosis without hyperthyroidism and an increased RAIU over the pelvis suggests struma ovarii. A low sTSH with normal T3 and FTI or fT4 indicates subclinical hyperthyroidism or TSH suppression by nonthyroidal factors (e.g., corticosteroid administration or starvation).
References
1. Helfand M, Redfern CC. Screening for thyroid disease: an update. Ann Intern Med 1998;129:144–158.
2. Hennessey JV. Diagnosis and management of thyrotoxicosis. Am Fam Physician 1996;54:1315–1324.
3. Thyroid Guidelines Task Force of the American Association of Clinical Endocrinologists and the American College of Endocrinology. AACE Clinical Practice Guidelines for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism. Endocrine Prac 1995;1:54–62.
4. Trivalle C, Doucet J, Chassagne P, et al. Differences in the signs and symptoms of hyperthyroidism in older and younger patients. J Am Geriatr Soc 1996;44:50–53.
5. Sakiyama R. Thyroiditis: a clinical review. Am Fam Physician 1993;48:615–621.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Thyroid Enlargement/Goiter:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Laboratory testing. The sensitive TSH (sTSH) assay is the single best test to evaluate thyroid status. Elevated sTSH is highly suggestive of hypothyroidism (Chapter 14.4). If sTSH is suppressed, an elevated free thyroxine index (FTI) or free thyroxine (fT4) measured directly, confirms thyrotoxicosis (Chapter 14.8). In a patient with a suppressed sTSH and a normal FTI or fT4, serum triiodothyronine (T3) should be measured to assess for possible T3 thyrotoxicosis.
B. Diagnostic imaging. Nuclear scans and ultrasound studies are not warranted in the routine evaluation of simple or multinodular goiter (4). Ultrasonography may be helpful in patients with equivocal findings on palpation. Symptoms suggestive of substernal mechanical pressure require evaluation, usually by computed tomography (CT) or magnetic resonance imaging (MRI).
C. Other tests. Fine needle aspiration biopsy (FNAB) should be performed in cases of a solitary or dominant nodule found by palpation. Pulmonary function tests are warranted with evidence of inspiratory impairment. Barium swallow is indicated to evaluate goiter-associated dysphagia.
Diagnostic assessment
The evaluation of goiter focuses on the history, thyroid palpation, and functional status of the gland. An asymptomatic patient with a simple or multinodular goiter associated with a normal metabolic state does not necessarily require further diagnostic studies or treatment. Periodic assessment, at least annually, to evaluate growth, function, and symptoms is warranted. A palpable solitary nodule or dominant nodule in a multinodular gland should be evaluated by FNAB or excisional biopsy (Chapter 14.7). Goiter with compressive symptoms requires CT or MRI evaluation and referral for probable surgery. Further assess a goiter associated with an abnormal metabolic state as outlined for hypothyroidism (Chapter 14.4) or thyrotoxicosis (Chapter 14.8). Thyroid hormone suppression of any goiter type is controversial, and the risks associated with subclinical hyperthyroidism must be included in the risk-to-benefit analysis (5).
References
1. Petrone LR. A primary care approach to the adult patient with nodular thyroid disease. Arch Fam Med 1996;5:92–100.
2. Siminoski K. Does this patient have a goiter? JAMA 1995;273:813–817.
3. Peter HJ, Burgi U, Gerber H. Pathogenesis of nontoxic diffuse and nodular goiter. In: Braverman LE, Utiger RD, eds. Werner and Ingbar’s the thyroid, 7th ed. Philadelphia: JB Lippincott, 1996:890–895.
4. Tan GH, Gharib H. Thyroid nodular disease: diagnostic evaluation and management [Letter]. Arch Intern Med 1997;157:575.
5. Gharib H, Mazzaferri EL. Thyroxine suppressive therapy in patients with nodular thyroid disease. Ann Intern Med 1998;128:386–394.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Neck Mass/Thyroid Enlargement:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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
Exophthalmos:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the assessment by taking the patient’s vital signs, noting 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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Thyroid enlargement:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical assessment by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. (See Palpating the thyroid gland, page 650.)
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 usually continuous.
» 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
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