Diagnosis of Hashimoto's Thyroiditis
Diagnostic Test list for Hashimoto's Thyroiditis:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Hashimoto's Thyroiditis
includes:
Hashimoto's Thyroiditis Diagnosis: Book Excerpts
Tests and diagnosis discussion for Hashimoto's Thyroiditis:
Your doctor will perform a simple blood test that will be able to tell
if your body has the correct amount of thyroid hormones. This test
measures the blood TSH (Thyroid Stimulating Hormone) to determine if the
thyroid hormone levels are in the normal range. The range is set by your
doctor and should be discussed with you. Work with your doctor to find
what level is right for you. (Source: excerpt from Hashimoto's Thyroiditis: NWHIC)
Diagnostic Tests for Hashimoto's Thyroiditis: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Hashimoto's Thyroiditis.
EXOPHTHALMOS:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it bilateral or unilateral? Bilateral exophthalmos would suggest hyperthyroidism. Unilateral exophthalmos suggests orbital tumor, abscess, or aneurysm.
- If it is bilateral, are there signs of hyperthyroidism? If there are other indications of hyperthyroidism, Graves' disease would be the diagnosis.
- 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.
- Is there fever? Fever would suggest acute cellulitis, acute sinusitis, periostitis, or a cavernous sinus thrombosis.
- 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)
- 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
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
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
Non-Hodgkin's lymphoma:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis requires histologic evaluation of biopsied lymph nodes; of tonsils, bone marrow, liver, bowel, or skin; or of tissue removed during exploratory laparotomy. (Biopsy differentiates non-Hodgkin's lymphoma from Hodgkin's disease.) (See Classifying non-Hodgkin's lymphomas, page 142.)
Other tests include bone and chest X-rays, lymphangiography, liver and spleen scan, computed tomography scan of the abdomen and chest, positron emission tomography, and excretory urography. Laboratory tests include complete blood count (may show anemia), uric acid (elevated or normal), serum calcium (elevated if bone lesions are present), serum protein (normal), and liver function studies.
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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.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
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.)
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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
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
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
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
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 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.
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Source: Handbook of Diseases, 2003
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.
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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).
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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.
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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.
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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.
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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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