Causes of Hyperthyroidism

• Gastrointestinal and malabsorption disorders (e.g., celiac disease, Crohn's disease, cystic fibrosis, PUD)
  –Diarrhea is often present

• Depression
  –Weight loss is one diagnostic criterion
  –Most common cause of weight loss in outpatient populations

• Adrenal insufficiency
  –Anorexia, nausea, and fatigue are common
• Anorexia nervosa
  –May present with low albumin, parotid enlargement, lesions on knuckles and diminished tooth enamel from induced vomiting, and menstrual irregularities
• Failure to thrive (infants)
  –Parental neglect, emotional deprivation
  –Improper mixing of formula
  –Significant heart (shunts) or lung disease
  –Inborn errors of metabolism
• Intestinal parasites

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Source: In a Page: Signs and Symptoms, 2004

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

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Source: In a Page: Signs and Symptoms, 2004

Weight Gain: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Primary obesity due to overeating and a sedentary lifestyle
• Medication side effects (e.g., oral contraceptives, corticosteroids, antidepressants, benzodiazepines, hypoglycemics, and anticonvulsants)
• Overeating secondary to nicotine withdrawal, depression, binge phase of bulimia nervosa
• Pregnancy
• Pre-eclampsia/eclampsia
• Premenstrual syndrome
• Nephrotic syndrome
  –Renal loss of protein results in decreased intravascular oncotic pressure, leading to water “leakage” to extravascular compartments (e.g., edema, ascites)
  –Due to primary renal disease or secondary causes (e.g., diabetes mellitus)

• Acute or chronic liver disease
  –Decreased hepatic protein production results in decreased intravascular oncotic pressure, leading to water “leakage” to extravascular compartments (e.g., edema, ascites)
• Congestive heart failure
• Hypothyroidism
• Diabetes mellitus
• Polycystic ovarian syndrome
  –Associated with hirsutism, menstrual irregularities, insulin resistance, obesity
• Cushing's syndrome
  –Excess cortisol levels due to ACTH-secreting adrenal adenoma, adrenal hyperplasia, ACTH-secreting ectopic tumor, or ACTH-secreting pituitary adenoma (Cushing's disease)
• Less common etiologies (“zebras”) include hypothalamic lesions (e.g., tumor, infection), hyperphagia due to hyperthyroidism, acromegaly (growth hormone excess, usually due to a pituitary tumor), or growth hormone deficiency

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Source: In a Page: Signs and Symptoms, 2004

Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Infectious
  –The most common cause overall and can be divided into acute and chronic
  –Gastroenteritis most common infection
  –May be viral, bacterial, fungal, or parasitic
  –Estimated 21–37 million episodes a year in children under 5
  –Others include strep, osteomyelitis, EBV, TB

• Psychiatric/psychosocial
  –Anorexia nervosa
  –Bulimia
  –Depression
  –Rumination
  –Drugs: Cocaine, amphetamines, laxatives
• Gastrointestinal disorders
  –Gastroesophageal reflux disease
  –Inflammatory bowel disease
  –Hepatitis
  –Pancreatitis
  –Pancreatic insufficiency (e.g., CF, Shwachman syndrome)
  –Celiac disease
  –Sucrase-isomaltase deficiency
  –Fat malabsorption: Abetalipoproteinemia
  –Protein malabsorption: Hartnup disease
  –Superior mesenteric artery syndrome
• Nutritional
  –Dieting; inadequate caloric intake
  –Iron deficiency
  –Zinc deficiency
  –Neglect
• Metabolic/endocrine
  –Diabetes mellitus
  –Diabetes insipidus
  –Addison disease
  –Hyperthyroidism
  –Hypopituitarism
• Malignancy
• HIV
• Acute/chronic renal failure
• Inflammatory
  –Systemic lupus erythematosus
  –Juvenile rheumatoid arthritis
  –Sarcoidosis
• Neurologic
  –Increased ICP: Pseudotumor cerebri, mass
• Cardiopulmonary
  –Cystic fibrosis
  –Congenital heart disease
  –Congestive heart failure

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

Diarrhea – Chronic, No Blood or Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Osmotic: Presence of nonabsorbable solute, pH <5, volume <200 mL/day, normal electrolytes, stops with fasting
• Secretory: Mostly due to toxins, pH >6, volume >200 mL/day, no response to fasting, stool Na >70 mEq/L, negative reducing substances
• Toddler's diarrhea: Chronic nonspecific diarrhea, onset 3 months to 3 years of age, average 4–6 stools daily, due to excessive juice intake or low-fat diet
• Excessive intake of nonabsorbable solutes (lactulose, sorbitol, magnesium hydroxide)
• Congenital lactose deficiency: Very rare in infancy, but may occur in extremely premature infants; adult-onset type of hypolactasia may be seen in older children (over age 5), autosomal recessive, 15% white adults, 85% of black adults, 90% of Asian adults
• Secondary lactase deficiency: Follows a viral gastroenteritis, most commonly rotavirus, may persist for months
• Fructose intolerance
• Sucrase-isomaltase deficiency: Autosomal recessive, found in 0.2% of North Americans, symptoms commence on starting sucrose or glucose polymer-containing foods
• Glucose-galactose malabsorption: Rare, autosomal recessive disorder
• Infections
  –Giardiasis (most common infectious cause of chronic diarrhea in toddlers)
  –Cryptosporidium
  –Microsporidium
• Irritable bowel syndrome (IBS)
  –Abnormality of intestinal motility and pain perception with no organic basis
  –Abdominal pain associated with intermittent diarrhea or constipation
• Bacterial overgrowth: Enteric bacteria colonizes the upper small intestine
• Trehelase deficiency (trehelose is the sugar found in mushrooms)
• Zinc deficiency
  –Acrodermatitis enteropathica is typical rash
• Low-fat diet

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

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)

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

Diarrhea – Chronic, with Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Allergic enteritis: Typically cow's milk or soy in infants
• Inflammatory bowel disease (IBD)
• Cystic fibrosis (CF)
  –Chronic diarrhea may be the only sign
  –90% have pancreatic insufficiency (PI)
• Celiac disease (CD): Gluten sensitivity, increased incidence in selective IgA deficiency, DM, and Down syndrome
• Immune deficiency (e.g., hypogammaglobulinemia)
• Sucrase-isomaltase deficiency: Autosomal recessive, symptoms with starting sucrose or glucose polymer-containing diet
• Microvillus inclusion disease: Most common cause of persistent diarrhea in the neonatal period
• Schwachman-Diamond syndrome
  –Pancreatic insufficiency, neutropenia, short stature, skeletal abnormalities
• Johannson-Blizzard syndrome
  –Pancreatic insufficiency, scalp defects, agenesis of nasal cartilage, deafness, imperforate anus
• Whipple disease:
  –Tropheryma whippelii (actinomycete)
  –Diagnosed mainly in adults
  –Weight loss, diarrhea, and arthropathy
• Tropical sprue: Common in developing countries; folate deficiency and diarrhea
• Neural crest tumors: Pheochromocytoma, VIPoma, Zollinger-Ellison syndrome, carcinoid tumors
• Mastocytoma
• Neuroblastoma
• Abetalipoproteinemia
• Giardiasis, Strongyloides, coccidia
• AIDS
• Acrodermatitis enteropathica: Zinc deficiency, acral perioral and perianal rashes, consider underlying cystic fibrosis
• Mutational defects in ion transport proteins
  –Chloride-losing diarrhea: Rare, ileal chloride transport defect, maternal polyhydramnios
  –Congenital sodium diarrhea
• Tufting enteropathy (epithelial dysplasia)
• Enterokinase deficiency

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

Exophthalmos: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Cavernous sinus thrombosis

Dacryoadenitis

Unilateral, slowly progressive exophthalmos is the most common sign of dacryoadenitis. Assessment may also reveal limited extraocular movements (especially on elevation and abduction), ptosis, eyelid edema and erythema, conjunctival injection, eye pain, and diplopia

Foreign body in the eye

Hemangioma

Most common in young adults, this orbital tumor produces progressive exophthalmos, which may be mild or severe, unilateral or bilateral. Other signs and symptoms include ptosis, limited extraocular movements, and blurred vision.

Lacrimal gland tumor

Leiomyosarcoma

Most common in people ages 45 and older, leiomyosarcoma is characterized by slowlydeveloping, unilateral exophthalmos. Other effects include diplopia, impaired vision, and intermittent eye pain.

Orbital cellulitis

Commonly the result of sinusitis, this ocular emergency causes the sudden onset of unilateral exophthalmos, which may be mild or severe. Orbital cellulitis may also produce a fever, eye pain, a headache, malaise, conjunctival injection, tearing, eyelid edema and erythema, purulent discharge, and impaired extraocular movements.

Orbital choristoma

Orbital emphysema

Air leaking from the sinus into the orbit usually causes unilateral exophthalmos. Palpation of the globe elicits crepitation.

Parasite infestation

Usually, parasite infestation causes painless, progressive exophthalmos in one eye that may spread to the other eye. Associated findings include limited extraocular movement, diplopia, eye pain, and impaired visual acuity.

Scleritis (posterior)

The gradual onset of mild to severe unilateral exophthalmos is common with scleritis. Other signs and symptoms include severe eye pain, diplopia, papilledema, limited extraocular movement, and impaired visual acuity.

Thyrotoxicosis

» READ BOOK EXCERPT ONLINE »

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

Thyroid enlargement: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Hypothyroidism

Hypothyroidism is most prevalent in women and usually results from a dysfunction of the thyroid gland, which may be due to surgery, irradiation therapy, chronic autoimmune thyroiditis (Hashimoto’s disease), or inflammatory conditions, such as amyloidosis and sarcoidosis. Besides an enlarged thyroid, signs and symptoms include weight gain despite anorexia; fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Eventually, the face assumes a dull expression with periorbital edema.

Iodine deficiency

A goiter may result from a lack of iodine in the diet. If the goiter arises from a deficiency of iodine in the food or water of a particular area, it’s called an endemic goiter. Associated signs and symptoms of an endemic goiter include dysphagia, dyspnea, and tracheal deviation. This condition is uncommon in developed countries with iodized salt.

Thyroiditis

Thyroiditis, an inflammation of the thyroid gland, may be classified as acute or subacute. It may be due to bacterial or viral infections, in which case associated features include fever and thyroid tenderness. The most prevalent cause of spontaneous hypothyroidism, however, is an autoimmune reaction, as occurs in Hashimoto’s thyroiditis. Autoimmune thyroiditis usually produces no symptoms other than thyroid enlargement.

Thyrotoxicosis

Overproduction of thyroid hormone causes thyrotoxicosis. The most common form is Graves’disease, which may result from genetic or immunologic factors. Associated signs and symptoms include nervousness; heat intolerance; fatigue; weight loss despite increased appetite; diarrhea; sweating; palpitations; tremors; smooth, warm, flushed skin; fine, soft hair; exophthalmos; nausea and vomiting due to increased GI motility and peristalsis; and, in females, oligomenorrhea or amenorrhea.

Tumors

An enlarged thyroid may result from a malignant tumor or a nonmalignant tumor (such as an adenoma). A malignant tumor usually appears as a single nodule in the neck; a nonmalignant tumor may appear as multiple nodules in the neck. Associated signs and symptoms include hoarseness, loss of voice, and dysphagia.

Thyroid tissue contained in ovarian dermoid tumors can function autonomously or in combination with thyrotoxicosis. Pituitary tumors that secrete thyroid-stimulating hormone (TSH), a rare type, are the only cause of normal or high TSH levels in association with thyrotoxicosis. Finally, high levels of human chorionic gonadotropin, as seen in trophoblastic tumors and pregnant women, can cause thyrotoxicosis.

Other causes

Goitrogens

Goitrogens are drugs — such as lithium, sulfonamides, phenylbutazone, and para-aminosalicylic acid — and substances in foods that decrease thyroxine production. Foods containing goitrogens include peanuts, cabbage, soybeans, strawberries, spinach, rutabagas, and radishes.

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

Weight gain, excessive: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acromegaly

Acromegaly causes moderate weight gain. Other findings include coarsened facial features, prognathism, enlarged hands and feet, increased sweating, oily skin, deep voice, back and joint pain, lethargy, sleepiness, and heat intolerance. Occasionally, hirsutism may occur.

Diabetes mellitus

The increased appetite associated with diabetes mellitus may lead to weight gain, although weight loss sometimes occurs instead. Other findings include fatigue, polydipsia, polyuria, nocturia, weakness, polyphagia, and somnolence.

Hypercortisolism

Excessive weight gain, usually over the trunk and the back of the neck (buffalo hump), characteristically occurs in this disorder. Other cushingoid features include slender extremities, moon face, weakness, purple striae, emotional lability, and increased susceptibility to infection. Gynecomastia may occur in men; hirsutism, acne, and menstrual irregularities may occur in women.

Hyperinsulinism

Hyperinsulinism increases appetite, leading to weight gain. Emotional lability, indigestion, weakness, diaphoresis, tachycardia, visual disturbances, and syncope also occur.

Hypogonadism

Weight gain is common in hypogonadism. Prepubertal hypogonadism causes eunuchoid body proportions with relatively sparse facial and body hair and a high-pitched voice. Postpubertal hypogonadism causes loss of libido, impotence, and infertility.

Hypothalamic dysfunction

Conditions such as Laurence-Moon-Biedl syndrome cause a voracious appetite with subsequent weight gain, along with altered body temperature and sleep rhythms.

Hypothyroidism

With hypothyroidism, weight gain occurs despite anorexia. Related signs and symptoms include fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Myalgia, hoarseness, hypoactive deep tendon reflexes, bradycardia, and abdominal distention may occur. Eventually, the face assumes a dull expression with periorbital edema.

Nephrotic syndrome

With nephrotic syndrome, weight gain results from edema. In severe cases, anasarca develops — increasing body weight up to 50%. Related effects include abdominal distention, orthostatic hypotension, and lethargy.

Pancreatic islet cell tumor

Pancreatic islet cell tumor causes excessive hunger, which leads to weight gain. Other findings include emotional lability, weakness, malaise, fatigue, restlessness, diaphoresis, palpitations, tachycardia, visual disturbances, and syncope.

Preeclampsia

With preeclampsia, rapid weight gain (exceeding the normal weight gain of pregnancy) may accompany nausea and vomiting, epigastric pain, elevated blood pressure, and visual blurring or double vision.

Sheehan’s syndrome

Most common in women who experience severe obstetric hemorrhage, Sheeehan’s syndrome may cause weight gain.

Other causes

Drugs

Corticosteroids, phenothiazines, and tricyclic antidepressants cause weight gain from fluid retention and increased appetite. Other drugs that can lead to weight gain include hormonal contraceptives, which cause fluid retention; cyproheptadine, which increases appetite; and lithium, which can induce hypothyroidism.

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

Low birth weight: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

This section lists some fetal and placental causes of low birth weight as well as the associated signs and symptoms pres-ent in the neonate at birth.

Chromosomal aberrations

Abnormalities in the number, size, or configuration of chromosomes can cause low birth weight and possibly multiple congenital anomalies in a premature or SGA neonate

For example, a neonate with trisomy 21 (Down syndrome) may be SGA and have prominent epicanthal folds, a flat-bridged nose, a protruding tongue, palmar simian creases, muscular hypotonia, and an umbilical hernia.

Cytomegalovirus infection

Although low birth weight in cytomegalovirus infection is usually associated with premature birth, the neonate may be SGA

Assessment at birth may reveal these classic signs: petechiae and ecchymoses, jaundice, and hepatosplenomegaly, which increases for several days. The neonate may also have a high fever, lymphadenopathy, tachypnea, and dyspnea, along with prolonged bleeding at puncture sites.

Placental dysfunction

Low birth weight and a wasted appearance occur in an SGA neonate

He may be symmetrically short or may appear relatively long for his low weight. Additional findings reflect the underlying cause. For example, if maternal hyperparathyroidism caused placental dysfunction, the neonate may exhibit muscle jerking and twitching, carpopedal spasm, ankle clonus, vomiting, tachycardia, and tachypnea.

Rubella (congenital)

Usually, the low-birth-weight neonate with this congenital rubellais born at term but is SGA

A characteristic “blueberry muffin” rash accompanies cataracts, purpuric lesions, hepatosplenomegaly, and a large anterior fontanel

Abnormal heart sounds, if present, vary with the type of associated congenital heart defect.

Varicella (congenital)

Low birth weight is accompanied by cataracts and skin vesicles.

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

Weight loss, excessive: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Adrenal insufficiency

Weight loss occurs with adrenal insufficiency, along with anorexia, weakness, fatigue, irritability, syncope, nausea, vomiting, abdominal pain, and diarrhea or constipation. Hyperpigmentation may occur at the joints, belt line, palmar creases, lips, gums, tongue, and buccal mucosa.

Anorexia nervosa

Anorexia nervosa is a psychogenic disorder, most common in young women, and is characterized by a severe, self-imposed weight loss ranging from 10% to 50% of premorbid weight, which typically was normal or not more than 5 lb (2.3 kg) over ideal weight. Related findings include skeletal muscle atrophy, loss of fatty tissue, hypotension, constipation, dental caries, susceptibility to infection, blotchy or sallow skin, cold intolerance, hairiness on the face and body, dryness or loss of scalp hair, and amenorrhea. The patient usually demonstrates restless activity and vigor and may also have a morbid fear of becoming fat. Self-induced vomiting or use of laxatives or diuretics may lead to dehydration or to metabolic alkalosis or acidosis.

Cancer

Weight loss is often a sign of cancer. Other findings reflect the type, location, and stage of the tumor and can include fatigue, pain, nausea, vomiting, anorexia, abnormal bleeding, and a palpable mass.

Crohn’s disease

Weight loss occurs with chronic cramping, abdominal pain, and anorexia. Other signs and symptoms include diarrhea, nausea, fever, tachycardia, abdominal tenderness and guarding, hyperactive bowel sounds, abdominal distention, and pain. Perianal lesions and a palpable mass in the right or left lower quadrant may also be present.

Cryptosporidiosis

Weight loss may occur with cryptosporidiosis, an opportunistic protozoan infection. Other findings include profuse watery diarrhea, abdominal cramping, flatulence, anorexia, malaise, fever, nausea, vomiting, and myalgia.

Depression

Weight loss or weight gain may occur with severe depression, along with insomnia or hypersomnia, anorexia, apathy, fatigue, and feelings of worthlessness. Indecisiveness, incoherence, and suicidal thoughts or behavior may also occur.

Diabetes mellitus

Weight loss may occur with diabetes mellitus, despite increased appetite. Other findings include polydipsia, weakness, fatigue, and polyuria with nocturia.

Esophagitis

Painful inflammation of the esophagus leads to temporary avoidance of eating and subsequent weight loss. Intense pain in the mouth and anterior chest occurs, along with hypersalivation, dysphagia, tachypnea, and hematemesis. If a stricture develops, dysphagia and weight loss will recur.

Gastroenteritis

Malabsorption and dehydration cause weight loss in gastroenteritis. The loss may be sudden in acute viral infections or reactions or gradual in parasitic infection. Other findings include poor skin turgor, dry mucous membranes, tachycardia, hypotension, diarrhea, abdominal pain and tenderness, hyperactive bowel sounds, nausea, vomiting, fever, and malaise.

Leukemia

Acute leukemia causes progressive weight loss accompanied by severe prostration; high fever; swollen, bleeding gums; and bleeding tendencies. Dyspnea, tachycardia, palpitations, and abdominal or bone pain may occur. As the disease progresses, neurologic symptoms may eventually develop.

Chronic leukemia, which occurs insidiously in adults, causes progressive weight loss with malaise, fatigue, pallor, enlarged spleen, bleeding tendencies, anemia, skin eruptions, anorexia, and fever.

Lymphoma

Hodgkin’s disease and non-Hodgkin’s lymphoma cause gradual weight loss. Associated findings include fever, fatigue, night sweats, malaise, hepatosplenomegaly, and lymphadenopathy. Scaly rashes and pruritus may develop.

Pulmonary tuberculosis

Pulmonary tuberculosis causes gradual weight loss, along with fatigue, weakness, anorexia, night sweats, and low-grade fever. Other clinical effects include a cough with bloody or mucopurulent sputum, dyspnea, and pleuritic chest pain. Examination may reveal dullness on percussion, crackles after coughing, increased tactile fremitus, and amphoric breath sounds.

Stomatitis

Inflammation of the oral mucosa (usually red, swollen, and ulcerated) in stomatitis causes weight loss due to decreased eating. Associated findings include fever, increased salivation, malaise, mouth pain, anorexia, and swollen, bleeding gums.

Thyrotoxicosis

With thyrotoxicosis, increased metabolism causes weight loss. Other characteristic signs and symptoms include nervousness, heat intolerance, diarrhea, increased appetite, palpitations, tachycardia, diaphoresis, fine tremor, and possibly an enlarged thyroid and exophthalmos. A ventricular or atrial gallop may be heard.

Other causes

Drugs

Amphetamines and inappropriate dosage of thyroid preparations commonly lead to weight loss. Laxative abuse may cause a malabsorptive state that leads to weight loss. Chemotherapeutic agents cause stomatitis or nausea and vomiting, which, when severe, causes weight loss.

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

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

Exophthalmos commonly results from hyperthyroidism, particularly ophthalmic Graves’disease in which the eyeballs are displaced forward and the lids retract. Unilateral exophthalmos may also result from trauma (such as fracture of the ethmoid bone, which allows air from the sinus to enter the orbital tissue, displacing soft tissue and the eyeball). Exophthalmos may also stem from hemorrhage, varicosities, thrombosis, and edema, all of which similarly displace one or both eyeballs.

Other systemic and ocular causes include:

❑ infection — orbital cellulitis, panophthalmitis, and infection of the lacrimal gland or orbital tissues

❑ parasitic cysts — in surrounding tissue

❑ pseudoexophthalmos paralysis of extraocular muscles — relaxation of eyeball retractors, congenital macrophthalmia, and high myopia

❑ tumors and neoplastic diseases — in children, rhabdomyosarcomas, leukemia, gliomas of the optic nerve, dermoid cysts, teratomas, metastatic neuroblastomas, and lymphoma; in adults, lacrimal gland tumors, mucoceles, cavernous hemangioma, meningiomas, metastatic carcinomas, and lymphoma.

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

Hyperthyroidism: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Hyperthyroidism may result from both genetic and immunologic factors. An increased incidence of this disorder in monozygotic twins, for example, points to an inherited factor, probably an autosomal recessive gene. This disease occasionally coexists with abnormal iodine metabolism and other endocrine abnormalities, such as diabetes mellitus, hyperparathyroidism, and thyroiditis. Hyperthyroidism is also associated with autoantibody production (thyroid-stimulating immunoglobulin and thyroid-stimulating hormone [TSH]-binding inhibitory immunoglobulin), possibly due to a defect in suppressor–T-lymphocyte function that allows the formation of autoantibodies.

In latent hyperthyroidism, excessive dietary intake of iodine and, possibly, stress can precipitate clinical hyperthyroidism. In a person with inadequately treated hyperthyroidism, stress — including surgery, infection, toxemia of pregnancy, and diabetic ketoacidosis — can precipitate thyroid storm. (See Other forms of hyperthyroidism.)

Incidence of Graves’ disease is highest between ages 30 and 40, especially in people with family histories of thyroid abnormalities; only 5% of hyperthyroid patients are younger than age 15.

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

Simple goiter: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Simple goiter occurs when the thyroid gland can’t secrete enough thyroid hormone to meet metabolic requirements. As a result, the thyroid gland enlarges to compensate for inadequate hormone synthesis, a compensation that usually overcomes mild to moderate hormonal impairment. Because thyroid-stimulating hormone (TSH) levels are generally within normal limits in patients with simple goiter, goitrogenicity probably results from impaired intrathyroidal hormone synthesis and depletion of glandular iodine, which increases the thyroid gland’s sensitivity to TSH. However, increased levels of TSH may be transient and therefore missed.

Endemic goiter usually results from inadequate dietary intake of iodine, which leads to inadequate secretion of thyroid hormone. Since the introduction of iodized salt in the United States, cases of endemic goiter have virtually disappeared.

Sporadic goiter commonly results from the ingestion of large amounts of goitrogenic foods or the use of goitrogenic drugs. Goitrogenic foods, such as rutabagas, cabbage, soybeans, peanuts, peaches, peas, strawberries, spinach, and radishes, contain agents that decrease thyroxine (T₄) production. Goitrogenic drugs include propylthiouracil, iodides, phenylbutazone, para-aminosalicylic acid, cobalt, and lithium. In a pregnant woman, these substances may cross the placenta and affect the fetus.

Inherited defects may be responsible for insufficient T₄ synthesis or impaired iodine metabolism. Because families tend to congregate in a single geographic area, this familial factor may contribute to the incidence of both endemic and sporadic goiters.

Females are more commonly affected than males. Incidence increases after age 40.  

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

Thyroid enlargement: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Hypothyroidism

This disorder, which is most prevalent in women, usually results from a dysfunction of the thyroid gland caused by surgery, irradiation therapy, chronic autoimmune thyroiditis (Hashimoto’s disease), or inflammatory conditions, such as amyloidosis and sarcoidosis. Besides an enlarged thyroid, signs and symptoms include weight gain despite anorexia; fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Eventually, the face assumes a dull expression with periorbital edema.

Iodine deficiency

A goiter may result from a lack of iodine in the diet. A goiter that arises from a deficiency of iodine in the food or water of a particular area is called an endemic goiter. Associated signs and symptoms of an endemic goiter include dysphagia, dyspnea, and tracheal deviation. This condition is uncommon in developed countries with iodized salt.

Thyroiditis

Thyroiditis, an inflammation of the thyroid gland, may be classified as acute or subacute. It may be due to bacterial or viral infections, in which case associated features include fever and thyroid tenderness. The most prevalent cause of spontaneous hypothyroidism, however, is an autoimmune reaction, as occurs in Hashimoto’s thyroiditis. Autoimmune thyroiditis usually produces no symptoms other than thyroid enlargement.

Thyrotoxicosis

Overproduction of thyroid hormone causes thyrotoxicosis. The most common form is Graves’disease, which may result from genetic or immunologic factors. Associated signs and symptoms include nervousness; heat intolerance; fatigue; weight loss despite increased appetite; diarrhea; diaphoresis; palpitations; tremors; smooth, warm, flushed skin; fine, soft hair; exophthalmos; nausea and vomiting due to increased GI motility and peristalsis; and, in females, oligomenorrhea or amenorrhea.

Tumors

An enlarged thyroid may result from a malignant tumor or a nonmalignant tumor (such as an adenoma). A malignant tumor usually appears as a single nodule in the neck; a nonmalignant tumor may appear as multiple nodules in the neck. Associated signs and symptoms include hoarseness, loss of voice, and dysphagia.

Thyroid tissue contained in ovarian dermoid tumors can function autonomously or in combination with thyrotoxicosis. Pituitary tumors that secrete thyroid-stimulating hormone (TSH), a rare type, are the only cause of normal or high TSH levels in association with thyrotoxicosis. Finally, high levels of human chorionic gonadotropin, as seen in trophoblastic tumors and pregnant women, can cause thyrotoxicosis.

Other causes

Goitrogens

Goitrogens are drugs and substances in foods that decrease thyroxine production. Drugs containing goitrogens include lithium, sulfonamides, and para-aminosalicylic acid. Foods containing goitrogens include peanuts, cabbage, soybeans, strawberries, spinach, rutabagas, and radishes.

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

Weight gain, excessive: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acromegaly

This disorder causes moderate weight gain. Other findings include coarsened facial features, prognathism, enlarged hands and feet, increased sweating, oily skin, deep voice, back and joint pain, lethargy, sleepiness, heat intolerance and, occasionally, hirsutism.

Cushing’s syndrome (hypercortisolism)

Excessive weight gain, usually over the trunk and the back of the neck (buffalo hump), characteristically occurs in this disorder. Other cushingoid features include slender extremities, moon face, weakness, purple striae, emotional lability, and increased susceptibility to infection. Gynecomastia may occur in men; hirsutism, acne, and menstrual irregularities may occur in women.

Diabetes mellitus

The increased appetite associated with this disorder may lead to weight gain, although weight loss sometimes occurs instead. Other findings include fatigue, polydipsia, polyuria, nocturia, weakness, polyphagia, and somnolence.

Heart failure

Despite anorexia, weight gain may result from edema. Other typical findings include paroxysmal nocturnal dyspnea, orthopnea, and fatigue.

Hyperinsulinism

This disorder increases appetite, leading to weight gain. Emotional lability, indigestion, weakness, diaphoresis, tachycardia, visual disturbances, and syncope also occur.

Hypogonadism

Weight gain is common in this disorder. Prepubertal hypogonadism causes eunuchoid body proportions with relatively sparse facial and body hair and a high-pitched voice. Postpubertal hypogonadism causes loss of libido, impotence, and infertility.

Hypothalamic dysfunction

Conditions such as Laurence-Moon-Biedl syndrome cause a voracious appetite and subsequent weight gain along with altered body temperature and sleep rhythms.

Hypothyroidism

In this disorder, weight gain occurs despite anorexia. Related signs and symptoms include fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Myalgia, hoarseness, hypoactive deep tendon reflexes, bradycardia, and abdominal distention may occur. Eventually, the face assumes a dull expression with periorbital edema.

Metabolic syndrome

This syndrome, previously called syndrome X, consists of a group of disorders that affect metabolism, including excessive weight gain (usually in the central abdomen), hypertension (blood pressure greater than 135/85 mm Hg), abnormal cholesterol levels (high low-density lipoprotein and triglyceride levels, low high-density lipoprotein level), and high insulin levels. Inefficient use of insulin in the body is thought to be a major contributor to metabolic syndrome, as are physical inactivity, poor diet, and genetic factors. Individuals with metabolic syndrome are at a significantly increased risk for heart disease, stroke, and diabetes. Treatment typically involves exercising, following a heart-healthy diet, and refraining from smoking; medical therapy may be prescribed to treat the individual disorders.

Nephrotic syndrome

In this syndrome, weight gain results from edema. Severe edema (anasarca) can increase body weight by up to 50%. Related effects include abdominal distention, orthostatic hypotension, and lethargy.

Pancreatic islet cell tumor

This type of tumor causes excessive hunger, which leads to weight gain. Other findings include emotional lability, weakness, malaise, fatigue, restlessness, diaphoresis, palpitations, tachycardia, visual disturbances, and syncope.

Preeclampsia

In this disorder, rapid weight gain (exceeding the normal weight gain of pregnancy) may accompany nausea and vomiting, epigastric pain, elevated blood pressure, and blurred or double vision.

Sheehan’s syndrome

Most common in women who experience severe obstetric hemorrhage, this syndrome may cause weight gain caused by impaired pituitary gland function.

Other causes

Drugs

Corticosteroids, phenothiazines, and tricyclic antidepressants cause weight gain from fluid retention and increased appetite. Other drugs that can lead to weight gain include hormonal contraceptives, which cause fluid retention; cyproheptadine, which increases appetite; and lithium, which can induce hypothyroidism.

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

Exophthalmos [Proptosis]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Cavernous sinus thrombosis

This disorder usually causes sudden onset of pulsating unilateral exophthalmos. Accompanying it may be eyelid edema, decreased or absent pupillary reflexes, limited extraocular movement, and impaired visual acuity. Other features include high fever with chills, papilledema, headache, nausea, vomiting, somnolence and, rarely, seizures.

Dacryoadenitis

Unilateral, slowly progressive exophthalmos is the most common sign of dacryoadenitis. Assessment may also reveal limited extraocular movement (especially on elevation and abduction), ptosis, eyelid edema and erythema, conjunctival injection, eye pain, and diplopia.

Foreign body in the eye

When a foreign body enters the eye, exophthalmos may accompany other signs and symptoms of ocular trauma, such as eye pain, redness, and tearing.

Hemangioma

Most common in young adults, this orbital tumor produces progressive exophthalmos, which may be mild or severe and unilateral or bilateral. Other signs and symptoms include ptosis, limited extraocular movement, and blurred vision.

Hodgkin’s disease

In this disorder, unilateral exophthalmos may develop gradually along with eyelid edema, diplopia, and a palpable eyelid mass. More characteristic findings include painless swelling of one or more lymph nodes, intermittent fever, weight loss, fatigue, malaise, night sweats, hepatosplenomegaly, and pruritus.

Lacrimal gland tumor

Exophthalmos usually develops slowly in one eye, causing its downward displacement toward the nose. The patient may also have ptosis and eye deviation and pain.

Leiomyosarcoma

Most common in people ages 45 and older, this tumor is characterized by slowly developing unilateral exophthalmos. Other effects include diplopia, impaired vision, and intermittent eye pain.

Leukemia

When leukemia causes intraorbital hemorrhage, mild to moderate bilateral exophthalmos and lacrimal gland enlargement also result. Associated signs and symptoms include bleeding tendency, fever, arthralgia, pallor, weakness, hepatosplenomegaly and, possibly, lymphadenopathy.

Lymphangioma

Hemorrhage of this congenital tumor causes unilateral or bilateral exophthalmos, among other signs.

Neuroblastoma

This highly malignant tumor, the most common extracranial solid tumor of childhood, may produce exophthalmos.

Ocular tuberculosis

Occasionally, this rare disease causes progressive exophthalmos accompanied by ptosis, painless eyelid edema and erythema, and enlarged lacrimal glands. Examination may reveal yellow or white fat deposits on the cornea and small white nodules in the iris.

Optic nerve meningioma

This tumor usually produces unilateral exophthalmos and a swollen temple. Impaired visual acuity, visual field deficits, and headache may occur.

Orbital cellulitis

Commonly the result of sinusitis, this ocular emergency causes sudden onset of unilateral exophthalmos, which may be mild or severe. Orbital cellulitis may also produce eye pain, conjunctival injection, tearing, eyelid edema and erythema, a purulent discharge, and limited extraocular movement as well as fever, headache, and malaise.

Orbital choristoma

A common sign of this benign tumor, progressive exophthalmos may be associated with diplopia and blurred vision.

Orbital emphysema

Air leaking from the sinus into the orbit usually causes unilateral exophthalmos. Palpation of the globe elicits crepitation.

Orbital pseudotumor

Progressive unilateral exophthalmos characterizes this uncommon disorder. Limited extraocular movement, eyelid edema, eye pain, and diplopia may also occur.

Parasite infestation

Usually, this disorder causes painless progressive exophthalmos in one eye that may spread to the other eye. Associated findings include limited extraocular movement, diplopia, eye pain, and impaired visual acuity.

Scleritis (posterior)

Gradual onset of mild to severe unilateral exophthalmos is common in scleritis. Other signs and symptoms include severe eye pain, diplopia, papilledema, limited extraocular movement, and impaired visual acuity.

Thyrotoxicosis

Although a classic sign of this disorder, exophthalmos is absent in many patients. It’s usually bilateral, progressive, and severe. Associated ocular features include ptosis, increased tearing, lid lag and edema, photophobia, conjunctival injection, diplopia, and decreased visual acuity. Other findings include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, sweating, diarrhea, tremors, palpitations, and tachycardia.

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

Low birth weight: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

This section lists some fetal and placental causes of low birth weight as well as the associated signs and symptoms present in the neonate at birth.

Chromosomal aberrations

Abnormalities in the number, size, or configuration of chromosomes can cause low birth weight and possibly multiple congenital anomalies in a premature or SGA neonate. For example, a neonate with trisomy 21 (Down syndrome) may be SGA and have prominent epicanthal folds, a flat-bridged nose, a protruding tongue, palmar simian creases, muscular hypotonia, and an umbilical hernia.

Cytomegalovirus infection

Although low birth weight in this disorder is usually associated with premature birth, some neonates may be SGA. Assessment at birth may reveal these classic signs: petechiae and ecchymoses, jaundice, and hepatosplenomegaly, which increases for several days. The neonate may also have a high fever, lymphadenopathy, tachypnea, and dyspnea, along with prolonged bleeding at puncture sites.

Placental dysfunction

Low birth weight and a wasted appearance occur in an SGA neonate. The neonate may be symmetrically short or may appear relatively long for his low weight. Additional findings reflect the underlying cause. For example, if maternal hyperparathyroidism caused placental dysfunction, the neonate may exhibit muscle jerking and twitching, carpopedal spasm, ankle clonus, vomiting, tachycardia, and tachypnea.

Rubella (congenital)

Usually, the low-birth-weight neonate with this disease is born at term but is SGA. A characteristic “blueberry muffin” rash accompanies cataracts, purpuric lesions, hepatosplenomegaly, and a large anterior fontanel. Abnormal heart sounds, if present, vary with the type of associated congenital heart defect.

Toxoplasmosis (congenital)

The low-birth-weight neonate may be either premature or SGA and may have hydrocephalus or microcephalus. Associated findings include fever, seizures, lymphadenopathy, hepatosplenomegaly, jaundice, and rash. Other defects, which may occur months or years later, include strabismus, blindness, epilepsy, and mental retardation.

Varicella (congenital)

Low birth weight is accompanied by cataracts and skin vesicles.

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

Weight loss, excessive: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adrenal insufficiency

Weight loss occurs in this disorder along with anorexia, weakness, fatigue, irritability, syncope, nausea, vomiting, abdominal pain, and diarrhea or constipation. Hyperpigmentation may occur at the joints, belt line, palmar creases, lips, gums, tongue, and buccal mucosa.

Anorexia nervosa

This psychogenic disorder, most common in young women, is characterized by a severe, self-imposed weight loss ranging from 10% to 50% of premorbid weight, which typically was normal or no more than 5 lb (2.3 kg) over ideal weight. Related findings include skeletal muscle atrophy, loss of fatty tissue, hypotension, constipation, dental caries, susceptibility to infection, blotchy or sallow skin, cold intolerance, hairiness on the face and body, dryness or loss of scalp hair, and amenorrhea. The patient usually demonstrates restless activity and vigor and may have a morbid fear of becoming fat. Self-induced vomiting or use of laxatives or diuretics may lead to dehydration or to metabolic alkalosis or acidosis.

Cancer

Weight loss can be a sign of many types of cancer. Other findings reflect the type, location, and stage of the tumor and can include fatigue, pain, nausea, vomiting, anorexia, abnormal bleeding, and a palpable mass.

Crohn’s disease

Weight loss occurs with chronic cramping, abdominal pain, and anorexia. Other signs and symptoms include diarrhea, nausea, fever, tachycardia, hyperactive bowel sounds, and abdominal distention, tenderness, and guarding. Perianal lesions and a palpable mass in the right or left lower quadrant may also be present.

Cryptosporidiosis

This opportunistic protozoan infection may cause weight loss, profuse watery diarrhea, abdominal cramping, flatulence, anorexia, nausea, vomiting, malaise, fever, and myalgia.

Depression

Severe depression may cause weight loss or weight gain along with insomnia or hypersomnia, anorexia, apathy, fatigue, and feelings of worthlessness. Indecisiveness, incoherence, and suicidal thoughts or behavior may also occur.

Diabetes mellitus

In this disorder, weight loss may occur despite increased appetite. Other findings include polydipsia, weakness, fatigue, and polyuria with nocturia.

Esophagitis

Painful inflammation of the esophagus leads to temporary avoidance of eating and subsequent weight loss. Intense pain in the mouth and anterior chest is accompanied by hypersalivation, dysphagia, tachypnea, and hematemesis. If a stricture develops, dysphagia and weight loss will recur.

Gastroenteritis

Malabsorption and dehydration cause weight loss in this disorder. The weight loss may be sudden in acute viral infections or reactions or gradual in parasitic infection. Other findings include poor skin turgor, dry mucous membranes, tachycardia, hypotension, diarrhea, abdominal pain and tenderness, hyperactive bowel sounds, nausea, vomiting, fever, and malaise.

Herpes simplex type 1

Painful fluid-filled blisters in and around the mouth make eating painful, causing decreased food intake and weight loss.

Leukemia

Acute leukemia causes progressive weight loss accompanied by severe prostration; high fever; swollen, bleeding gums; and other bleeding tendencies. Dyspnea, tachycardia, palpitations, and abdominal or bone pain may occur. As the disease progresses, neurologic symptoms may eventually develop.

Chronic leukemia, which occurs insidiously in adults, causes progressive weight loss with malaise, fatigue, pallor, enlarged spleen, bleeding tendencies, anemia, skin eruptions, anorexia, and fever.

Lymphomas

Hodgkin’s disease and malignant lymphoma cause gradual weight loss. Associated findings include fever, fatigue, night sweats, malaise, hepatosplenomegaly, and lymphadenopathy. Scaly rashes and pruritus may develop.

Pulmonary tuberculosis

This disorder causes gradual weight loss along with fatigue, weakness, anorexia, night sweats, and low-grade fever. Other clinical effects include a cough with bloody or mucopurulent sputum, dyspnea, and pleuritic chest pain. Examination may reveal dullness on percussion, crackles after coughing, increased tactile fremitus, and amphoric breath sounds.

Stomatitis

Inflammation of the oral mucosa (which are usually red, swollen, and ulcerated) in this disorder causes weight loss due to decreased eating. Associated findings include fever, increased salivation, malaise, mouth pain, anorexia, and swollen, bleeding gums.

Thyrotoxicosis

In this disorder, increased metabolism causes weight loss. Other characteristic signs and symptoms include nervousness, heat intolerance, diarrhea, increased appetite, palpitations, tachycardia, diaphoresis, a fine tremor, and possibly an enlarged thyroid gland and exophthalmos. A ventricular or atrial gallop may be heard.

Ulcerative colitis

Weight loss is a late sign of this disorder, which is initially characterized by bloody diarrhea with pus or mucus. Other findings include weakness, crampy lower abdominal pain, hyperactive bowel sounds, tenesmus, anorexia, low-grade fever and, occasionally, nausea and vomiting. Constipation may occur late. Fulminant colitis causes severe and steady abdominal pain and diarrhea, high fever, and tachycardia.

Whipple’s disease

This rare disease causes progressive weight loss along with abdominal pain, diarrhea, steatorrhea, arthralgia, fever, hyperpigmentation, lymphadenopathy, and splenomegaly.

Other causes

Drugs

Amphetamines and inappropriate dosage of thyroid preparations commonly lead to weight loss. Laxative abuse may cause a malabsorptive state that leads to weight loss. Chemotherapeutic agents may result in weight loss from severe stomatitis.

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

Involuntary Weight Loss: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Diabetes

❑ Depression

❑ Inadequate intake

❑ Drugs

❑ Hyperthyroidism

❑ Occult cancer

❑ Low cardiac output

❑ Anorexia nervosa

❑ Malabsorption

❑ Chronic infection

❑ Adrenal insufficiency

❑ Emphysema

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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

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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

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Source: Field Guide to Bedside Diagnosis, 2007

Thyrotoxicosis: Causes
(Handbook of Diseases)

Thyrotoxicosis may result from genetic and immunologic factors.

❑ An increased incidence of this disorder in monozygotic twins points to an inherited factor, probably an autosomal recessive gene.

❑ This disease occasionally coexists with other endocrine abnormalities, such as diabetes mellitus, thyroiditis, and hyperparathyroidism.

❑ Thyrotoxicosis may also be caused by the production of autoantibodies (thyroid-stimulating immunoglobulin and thyroid-stimulating hormone [TSH]-binding inhibitory immuno-globulin), possibly because of a defect in suppressor-T-lymphocyte function that allows the formation of autoantibodies.

❑ In latent thyrotoxicosis, excessive dietary intake of iodine and, possibly, stress can precipitate clinical thyrotoxicosis.

❑ In a person with inadequately treated thyrotoxicosis, stress — including surgery, infection, toxemia of pregnancy, and diabetic ketoacidosis — can precipitate thyroid storm.

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Source: Handbook of Diseases, 2003

Goiter: Causes
(Handbook of Diseases)

Simple goiter occurs when the thyroid gland can’t produce and secrete enough thyroid hormone to meet metabolic requirements. As a result, the thyroid gland enlarges to compensate for inadequate hormone synthesis. Such compensation usually overcomes mild to moderate hormonal impairment.

Because thyroid-stimulating hormone (TSH) levels are generally within normal limits in patients with simple goiter, the disease probably results from impaired intrathyroidal hormone synthesis or depletion of glandular iodine, which increases the thyroid gland’s sensitivity to TSH. Thyroid growth-stimulating immunoglobulins can also cause gland enlargement. However, increased levels of TSH may be transient and therefore missed.

Endemic goiter

Endemic goiter usually results from inadequate dietary intake of iodine, which leads to inadequate production and secretion of thyroid hormone. The use of iodized salt prevents this deficiency.

Sporadic goiter

Sporadic goiter commonly results from the ingestion of large amounts of goitrogenic foods or the use of goitrogenic drugs.

Goitrogenic foods contain agents that decrease thyroxine (T₄) production. Such foods include rutabagas, cabbage, soybeans, peanuts, peaches, peas, strawberries, spinach, and radishes.

Goitrogenic drugs include propylthiouracil, methimazole, iodides, and lithium. In a pregnant woman, such substances may cross the placenta and affect the fetus.

Both types

Inherited defects may be responsible for insufficient T₄ synthesis or impaired iodine metabolism. Because families tend to congregate in a single geographic area, this familial factor may contribute to the incidence of both endemic and sporadic goiter.

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Source: Handbook of Diseases, 2003

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

Foreign body in the eye

When a foreign body enters the eye, exophthalmos may accompany other signs and symptoms of ocular trauma, such as eye pain, redness, and tearing. Loss of vision or blurred vision may occur in the affected eye.

Hemangioma

Most common in young adults, hemangioma is an orbital tumor that produces progressive exophthalmos, which may be mild or severe, unilateral or bilateral. Other signs and symptoms include ptosis, limited extraocular movements, and blurred vision.

Lacrimal gland tumor

In patients with a lacrimal gland tumor, exophthalmos usually develops slowly in one eye, causing its downward displacement toward the nose. The patient may also have ptosis, eye deviation, and pain.

Optic nerve meningioma

An optic nerve meningioma usually produces unilateral exophthalmos and a swollen temple. Impaired visual acuity, visual field deficits, and headache may occur.

Orbital cellulitis

Commonly the result of sinusitis, orbital cellulitis is an ocular emergency that causes sudden onset of unilateral exophthalmos, which may be mild or severe. It may also produce fever, eye pain, headache, malaise, conjunctival injection, tearing, eyelid edema and erythema, purulent discharge, and impaired extraocular movements.

Orbital choristoma

A common sign of orbital choristoma (a benign tumor), progressive exophthalmos may be associated with diplopia and blurred vision. A mass may be visible in the orbital area.

Orbital emphysema

With orbital emphysema, air leaking from the sinus into the orbit usually causes unilateral exophthalmos. Palpation of the globe elicits crepitation. The patient may report orbital pressure.

Parasite infestation

Usually, parasite infestation causes painless, progressive exophthalmos in one eye that may spread to the other eye. Associated findings include limited extraocular movement, diplopia, eye pain, and impaired visual acuity.

Scleritis (posterior)

Gradual onset of mild to severe unilateral exophthalmos is common with scleritis. Other signs and symptoms include severe eye pain, diplopia, papilledema, limited extraocular movement, and impaired visual acuity.

Thyrotoxicosis

Although a classic sign of thyrotoxicosis, exophthalmos is absent in many patients. It’s usually bilateral, progressive, and severe. Associated ocular features include ptosis, increased tearing, lid lag and edema, photophobia, conjunctival injection, diplopia, and decreased visual acuity. Other findings include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, sweating, diarrhea, tremors, palpitations, and tachycardia.

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

Thyroid enlargement: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Hypothyroidism

Besides an enlarged thyroid, signs and symptoms of hypothyroidism include weight gain despite anorexia; fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Eventually, the face assumes a dull expression with periorbital edema.

CULTURAL CUE:Goiters are common in areas of the world that are deficient in iodine, such as Asia, Latin America, Africa, and parts of Europe.

Thyroiditis

Autoimmune thyroiditis usually produces no symptoms other than thyroid enlargement. In subacute granulomatous thyroiditis, moderate thyroid enlargement may follow an upper respiratory infection or a sore throat. The thyroid may be painful and tender. Dysphagia may also occur.

Thyrotoxicosis

One of the classic features of thyrotoxicosis is an enlarged thyroid gland. Associated signs and symptoms include nervousness; heat intolerance; fatigue; weight loss despite increased appetite; diarrhea; sweating; palpitations; tremors; smooth, warm, flushed skin; fine, soft hair; exophthalmos; nausea and vomiting due to increased GI motility and peristalsis; and, in females, oligomenorrhea or amenorrhea.

Tumors

An enlarged thyroid may result from a malignant tumor or a nonmalignant tumor (such as an adenoma). A malignant tumor usually appears as a single nodule in the neck; a nonmalignant tumor may appear as multiple nodules in the neck. Associated signs and symptoms include hoarseness, loss of voice, and dysphagia.

Other causes

Goitrogens

Goitrogens are drugs and substances in foods that decrease thyroxine production. Drugs include lithium, sulfonamides, phenylbutazone, and para-aminosalicylic acid. Foods containing goitrogens include peanuts, cabbage, soybeans, strawberries, spinach, rutabagas, and radishes.

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

Weight gain, excessive: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Acromegaly

Acromegaly causes moderate weight gain. Other findings include coarsened facial features, prognathism, enlarged hands and feet, increased sweating, oily skin, deep voice, back and joint pain, lethargy, sleepiness, and heat intolerance. Occasionally, hirsutism may occur.

Diabetes mellitus

The increased appetite associated with diabetes mellitus may lead to weight gain, although weight loss sometimes occurs instead. Other findings include fatigue, polydipsia, polyuria, nocturia, weakness, polyphagia, and somnolence.

Heart failure

Despite anorexia, weight gain may result from edema. Other typical findings in heart failure include paroxysmal nocturnal dyspnea, tachypnea, tachycardia, nausea, orthopnea, and fatigue.

Hypercortisolism

Excessive weight gain, usually over the trunk and the back of the neck (buffalo hump), characteristically occurs in hypercortisolism. Other cushingoid features include slender extremities, moon face, weakness, purple striae, emotional lability, and increased susceptibility to infection. Gynecomastia may occur in men; hirsutism, acne, and menstrual irregularities may occur in women.

Hyperinsulinism

Hyperinsulinism increases appetite, leading to weight gain. Emotional lability, indigestion, weakness, diaphoresis, tachycardia, vision disturbances, and syncope also occur.

Hypogonadism

Weight gain is common in hypogonadism. Prepubertal hypogonadism causes eunuchoid body proportions with relatively sparse facial and body hair and a high-pitched voice. Postpubertal hypogonadism causes loss of libido, impotence, and infertility.

Hypothyroidism

With hypothyroidism, weight gain occurs despite anorexia. Related signs and symptoms include fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Myalgia, hoarseness, hypoactive deep tendon reflexes, bradycardia, and abdominal distention may occur. Eventually, the face assumes a dull expression with periorbital edema.

Nephrotic syndrome

With nephrotic syndrome, weight gain results from edema. In severe cases, anasarca develops — increasing body weight up to 50%. Related effects include abdominal distention, orthostatic hypotension, and lethargy.

Pancreatic islet cell tumor

Pancreatic islet cell tumor causes excessive hunger, which leads to weight gain. Other findings include emotional lability, weakness, malaise, fatigue, restlessness, diaphoresis, palpitations, tachycardia, vision disturbances, and syncope.

Preeclampsia

With preeclampsia, rapid weight gain (exceeding the normal weight gain of pregnancy) may accompany nausea and vomiting, epigastric pain, elevated blood pressure, and visual blurring or double vision.

Other causes

Drugs

Corticosteroids, phenothiazines, and tricyclic antidepressants cause weight gain from fluid retention and increased appetite. Other drugs that can lead to weight gain include hormonal contraceptives, which cause fluid retention; cyproheptadine, which increases appetite; and lithium, which can induce hypothyroidism.

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

Weight loss, excessive: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Adrenal insufficiency

Weight loss occurs with adrenal insufficiency, along with anorexia, weakness, fatigue, irritability, syncope, nausea, vomiting, abdominal pain, and diarrhea or constipation. Hyperpigmentation may occur at the joints, belt line, palmar creases, lips, gums, tongue, and buccal mucosa.

Anorexia nervosa

Anorexia nervosa, a psychogenic disorder that’s most common in young women, is characterized by a severe, self-imposed weight loss ranging from 10% to 50% of premorbid weight, which typically was normal or not more than 5 lb (2.3 kg) over ideal weight. Related findings include skeletal muscle atrophy, loss of fatty tissue, hypotension, constipation, dental caries, susceptibility to infection, blotchy or sallow skin, cold intolerance, hairiness on the face and body, dryness or loss of scalp hair, and amenorrhea. The patient usually demonstrates restless activity and vigor and may also have a morbid fear of becoming fat. Self-induced vomiting or use of laxatives or diuretics may lead to dehydration or to metabolic alkalosis or acidosis.

Cancer

Weight loss is often a sign of cancer. Other findings reflect the type, location, and stage of the tumor and can include fatigue, pain, nausea, vomiting, anorexia, abnormal bleeding, and a palpable mass.

Crohn’s disease

With Crohn’s disease, weight loss occurs with chronic cramping, abdominal pain, and anorexia. Other signs and symptoms include diarrhea, nausea, fever, tachycardia, abdominal tenderness and guarding, hyperactive bowel sounds, abdominal distention, and pain. Perianal lesions and a palpable mass in the right or left lower quadrant may also be present.

Cryptosporidiosis

Weight loss may occur with cryptosporidiosis, an opportunistic protozoan infection. Other findings include profuse watery diarrhea, abdominal cramping, flatulence, anorexia, malaise, fever, nausea, vomiting, and myalgia.

Depression

Weight loss or weight gain may occur with severe depression, along with insomnia or hypersomnia, anorexia, apathy, fatigue, and feelings of worthlessness. Indecisiveness, incoherence, and suicidal thoughts or behavior may also occur.

Diabetes mellitus

Weight loss may occur with diabetes mellitus, despite increased appetite. Other findings include polydipsia, weakness, fatigue, blurred vision, and polyuria with nocturia.

Esophagitis

Painful inflammation of the esophagus leads to temporary avoidance of eating and subsequent weight loss. Intense pain in the mouth and anterior chest occurs, along with hypersalivation, dysphagia, tachypnea, and hematemesis. If a stricture develops, dysphagia and weight loss will recur.

Gastroenteritis

Malabsorption and dehydration cause weight loss in gastroenteritis. The loss may be sudden in acute viral infections or reactions or gradual in parasitic infection. Other findings include poor skin turgor, dry mucous membranes, tachycardia, hypotension, diarrhea, abdominal pain and tenderness, hyperactive bowel sounds, nausea, vomiting, fever, and malaise.

Herpes simplex 1

With herpes simplex 1, painful fluid-filled blisters in and around the mouth, especially the tongue, gums, and cheeks, make eating painful causing decreased food intake and weight loss. Fever and pharyngitis may also occur.

Leukemia

Acute leukemia causes progressive weight loss accompanied by severe prostration; high fever; swollen, bleeding gums; and bleeding tendencies. Dyspnea, tachycardia, palpitations, and abdominal or bone pain may occur. As the disease progresses, neurologic symptoms may eventually develop.

Chronic leukemia, which occurs insidiously in adults, causes progressive weight loss with malaise, fatigue, pallor, enlarged spleen, bleeding tendencies, anemia, skin eruptions, anorexia, and fever.

Lymphoma

Hodgkin’s disease and non-Hodgkin’s lymphoma cause gradual weight loss. Associated findings include fever, fatigue, night sweats, malaise, hepatosplenomegaly, and lymphadenopathy. Scaly rashes and pruritus may develop.

Pulmonary tuberculosis

Pulmonary tuberculosis causes gradual weight loss, along with fatigue, weakness, anorexia, night sweats, and low-grade fever. Other clinical effects include a cough with bloody or mucopurulent sputum, dyspnea, and pleuritic chest pain. Examination may reveal dullness on percussion, crackles after coughing, increased tactile fremitus, and amphoric breath sounds.

Stomatitis

Inflammation of the oral mucosa (usually red, swollen, and ulcerated) in stomatitis causes weight loss due to decreased eating. Associated findings include fever, increased salivation, malaise, mouth pain, anorexia, and swollen, bleeding gums.

Thyrotoxicosis

With thyrotoxicosis, increased metabolism causes weight loss. Other characteristic signs and symptoms include nervousness, heat intolerance, diarrhea, increased appetite, palpitations, tachycardia, diaphoresis, fine tremor, and possibly an enlarged thyroid and exophthalmos. A ventricular or atrial gallop may be heard.

Ulcerative colitis

Weight loss is a late sign of ulcerative colitis, which is initially characterized by bloody diarrhea with pus or mucus. Weakness, crampy lower abdominal pain, tenesmus, anorexia, low-grade fever, and occasional nausea and vomiting may also occur. Bowel sounds are hyperactive, and constipation may occur late. With fulminant colitis, severe and steady abdominal pain and diarrhea, high fever, and tachycardia occur.

Other causes

Drugs

Amphetamines and inappropriate dosage of thyroid preparations commonly lead to weight loss. Laxative abuse may cause a malabsorptive state that leads to weight loss. Chemotherapeutic agents cause stomatitis, which, when severe, causes weight loss.

» READ BOOK EXCERPT ONLINE »

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

Growth Deficiency: Weight and Height: Principal Causes of Growth Deficiency: Weight and Height
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Normalvariations
   1. Constitutionaldelay of growth and maturation
   2. Genetic (familial) short stature
2. Disorders primarily affecting weight
   1. Intrauterinegrowth disturbance
   2. Undernutrition
   3. Excessive calorie wasting (vomiting,diarrhea, polyuria)
   4. Chronic disease
   5. Psychologic disorders
      1. Psychosocialdeprivation
      2. Anorexia nervosa
      3. Depression
      4. Psychosis
3. Disorders primarily affecting skeletalgrowth (height)
   1. Chromosomal abnormalities
   2. Dysmorphic syndromes
   3. Bone and cartilage disorders (osteochondrodysplasias)
   4. Endocrine disorders
      1. Hypothyroidism
      2. Glucocorticoid excess
      3. Growth hormone deficiency/insensitivity

» READ BOOK EXCERPT ONLINE »

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

Thyroid enlargement: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Hypothyroidism.Hypothyroidism causes an enlarged thyroid. Additional signs and symptoms include weight gain despite anorexia; fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Eventually, the face assumes a dull expression with periorbital edema.

Iodine deficiency.A deficiency of iodine in the food or water of a particular area may cause an endemic goiter. Associated signs and symptoms of an endemic goiter include dysphagia, dyspnea, and tracheal deviation. This condition is uncommon in developed countries with iodized salt.

Thyroiditis.Autoimmune thyroiditis usually produces no symptoms other than thyroid enlargement.

Thyrotoxicosis.Signs and symptoms of thyrotoxicosis include an enlarged thyroid, nervousness; heat intolerance; fatigue; weight loss despite increased appetite; diarrhea; sweating; palpitations; tremors; smooth, warm, flushed skin; fine, soft hair; exophthalmos; nausea and vomiting due to increased GI motility and peristalsis; and, in females, oligomenorrhea or amenorrhea.

Tumors.An enlarged thyroid may result from a malignant tumor or a nonmalignant tumor (such as an adenoma). Associated signs and symptoms include hoarseness, loss of voice, and dysphagia.

Thyroid tissue contained in ovarian dermoid tumors can function autonomously or in combination with thyrotoxicosis. Pituitary tumors that secrete thyroid-stimulating hormone (TSH), a rare type, are the only cause of normal or high TSH levels in association with thyrotoxicosis. Finally, high levels of human chorionic gonadotropin, as seen in trophoblastic tumors and pregnant women, can cause thyrotoxicosis.

Other causes

Goitrogens.Goitrogens are drugs—such as lithium, sulfonamides, phenylbutazone, and para-aminosalicylic acid—and substances in foods that decrease thyroxine production. Foods containing goitrogens include peanuts, cabbage, soybeans, strawberries, spinach, rutabagas, and radishes.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Weight gain, excessive: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acromegaly.Acromegaly causes moderate weight gain. Other findings include coarsened facial features, prognathism, enlarged hands and feet, increased sweating, oily skin, deep voice, back and joint pain, lethargy, sleepiness, and heat intolerance. Occasionally, hirsutism may occur.

Diabetes mellitus.The increased appetite associated with diabetes mellitus may lead to weight gain, although weight loss sometimes occurs initially. Other findings include fatigue, polydipsia, polyuria, nocturia, weakness, polyphagia, and somnolence.

Hypercortisolism.Excessive weight gain, usually over the trunk and the back of the neck (buffalo hump), characteristically occurs in hypercortisolism. Other cushingoid features include slender extremities, moon face, weakness, purple striae, emotional lability, and increased susceptibility to infection. Gynecomastia may occur in men; hirsutism, acne, and menstrual irregularities may occur in women.

Hyperinsulinism.Hyperinsulinism increases appetite, leading to weight gain. Emotional lability, indigestion, weakness, diaphoresis, tachycardia, vision disturbances, and syncope also occur.

Hypogonadism.Weight gain is common in hypogonadism. Prepubertal hypogonadism causes eunuchoid body proportions with relatively sparse facial and body hair and a high-pitched voice. Postpubertal hypogonadism causes loss of libido, impotence, and infertility.

Hypothalamic dysfunction.Conditions such as Laurence-Moon-Biedl syndrome cause a voracious appetite with subsequent weight gain, along with altered body temperature and sleep rhythms.

Hypothyroidism.With hypothyroidism, weight gain occurs despite anorexia. Related signs and symptoms include fatigue; cold intolerance; constipation; menorrhagia; slowed intellectual and motor activity; dry, pale, cool skin; dry, sparse hair; and thick, brittle nails. Myalgia, hoarseness, hypoactive deep tendon reflexes, bradycardia, and abdominal distention may occur. Eventually, the face assumes a dull expression with periorbital edema.

Metabolic syndrome.Metabolic syndrome, previously called syndrome X, consists of a group of disorders that affect metabolism, including excessive weight gain (usually in the central abdomen), hypertension (blood pressure greater than 135/85 mm Hg), abnormal cholesterol levels (high low-density lipoprotein and triglyceride levels, low high-density lipoprotein level), and high insulin levels.

Nephrotic syndrome.With nephrotic syndrome, weight gain results from edema. In severe cases, anasarca develops—increasing body weight up to 50%. Related effects include abdominal distention, orthostatic hypotension, and lethargy.

Pancreatic islet cell tumor.Pancreatic islet cell tumor causes excessive hunger, which leads to weight gain. Other findings include emotional lability, weakness, malaise, fatigue, restlessness, diaphoresis, palpitations, tachycardia, vision disturbances, and syncope.

Preeclampsia.With preeclampsia, rapid weight gain (exceeding the normal weight gain of pregnancy) may accompany nausea and vomiting, epigastric pain, elevated blood pressure, and blurred or double vision.

Sheehan's syndrome.Most common in women who experience severe obstetric hemorrhage, Sheehan's syndrome may cause weight gain.

Other causes

Drugs.Corticosteroids, phenothiazines, and tricyclic antidepressants cause weight gain from fluid retention and increased appetite. Other drugs that can lead to weight gain include hormonal contraceptives, which cause fluid retention; cyproheptadine, which increases appetite; and lithium, which can induce hypothyroidism.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Exophthalmos [Proptosis]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Cavernous sinus thrombosis.Usually, cavernous sinus thrombosis causes the sudden onset of pulsating, unilateral exophthalmos. Accompanying it may be eyelid edema, decreased or absent pupillary reflexes, and impaired extraocular movement and visual acuity. Other features include a high fever with chills, papilledema, a headache, nausea, vomiting, somnolence and, rarely, seizures.

Dacryoadenitis.Unilateral, slowly progressive exophthalmos is the most common sign of dacryoadenitis. Assessment may also reveal limited extraocular movements (especially on elevation and abduction), ptosis, eyelid edema and erythema, conjunctival injection, eye pain, and diplopia.

Foreign body in the eye.When a foreign body enters the eye, exophthalmos may accompany other signs and symptoms of ocular trauma, such as eye pain, redness, and tearing.

Hemangioma.This orbital tumor produces progressive exophthalmos, which may be mild or severe, unilateral or bilateral. Other signs and symptoms include ptosis, limited extraocular movements, and blurred vision.

Lacrimal gland tumor.Exophthalmos usually develops slowly in one eye, causing its downward displacement toward the nose. The patient may also have ptosis and eye deviation and pain.

Leiomyosarcoma.Leiomyosarcoma is characterized by slowlydeveloping, unilateral exophthalmos. Other effects include diplopia, impaired vision, and intermittent eye pain.

Orbital cellulitis.Commonly the result of sinusitis, this ocular emergency causes the sudden onset of unilateral exophthalmos, which may be mild or severe. Orbital cellulitis may also produce a fever, eye pain, a headache, malaise, conjunctival injection, tearing, eyelid edema and erythema, purulent discharge, and impaired extraocular movements.

Orbital choristoma.A common sign of this benign tumor, progressive exophthalmos may be associated with diplopia and blurred vision.

Orbital emphysema.Air leaking from the sinus into the orbit usually causes unilateral exophthalmos. Palpation of the globe elicits crepitation.

Parasite infestation.Usually, parasite infestation causes painless, progressive exophthalmos in one eye that may spread to the other eye. Associated findings include limited extraocular movement, diplopia, eye pain, and impaired visual acuity.

Scleritis (posterior).The gradual onset of mild to severe unilateral exophthalmos is common with scleritis. Other signs and symptoms include severe eye pain, diplopia, papilledema, limited extraocular movement, and impaired visual acuity.

Thyrotoxicosis.Although a classic sign of thyrotoxicosis, exophthalmos is absent in many patients. It's usually bilateral, progressive, and severe. Associated ocular features include ptosis, increased tearing, lid lag and edema, photophobia, conjunctival injection, diplopia, and decreased visual acuity. Other findings include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, sweating, diarrhea, tremors, palpitations, and tachycardia.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Low birth weight: Medical causes
(Nursing: Interpreting Signs and Symptoms)

This section lists some fetal and placental causes of low birth weight as well as the associated signs and symptoms present in the neonate at birth.

Chromosomal aberrations.Abnormalities in the number, size, or configuration of chromosomes can cause low birth weight and possibly multiple congenital anomalies in a premature or SGA neonate. For example, a neonate with trisomy 21 (Down syndrome) may be SGA and have prominent epicanthal folds, a flat-bridged nose, a protruding tongue, palmar simian creases, muscular hypotonia, and an umbilical hernia.

Cytomegalovirus infection.Although low birth weight in cytomegalovirus infection is usually associated with premature birth, the neonate may be SGA. Assessment at birth may reveal these classic signs: petechiae and ecchymoses, jaundice, and hepatosplenomegaly, which increases for several days. The neonate may also have a high fever, lymphadenopathy, tachypnea, and dyspnea, along with prolonged bleeding at puncture sites.

Placental dysfunction.With placental dysfunction, low birth weight and a wasted appearance occur in an SGA neonate. He may be symmetrically short or may appear relatively long for his low weight. Additional findings reflect the underlying cause. For example, if maternal hyperparathyroidism caused placental dysfunction, the neonate may exhibit muscle jerking and twitching, carpopedal spasm, ankle clonus, vomiting, tachycardia, and tachypnea.

Rubella (congenital).Usually, the low-birth-weight neonate with congenital rubella is born at term but is SGA. A characteristic “blueberry muffin” rash accompanies cataracts, purpuric lesions, hepatosplenomegaly, and a large anterior fontanel. Abnormal heart sounds, if present, vary with the type of associated congenital heart defect.

Varicella (congenital).With congenital varicella, low birth weight is accompanied by cataracts and skin vesicles.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Weight loss, excessive: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Adrenal insufficiency.Weight loss occurs with adrenal insufficiency, along with anorexia, weakness, fatigue, irritability, syncope, nausea, vomiting, abdominal pain, and diarrhea or constipation. Hyperpigmentation may occur at the joints, belt line, palmar creases, lips, gums, tongue, and buccal mucosa.

Anorexia nervosa.Anorexia nervosa is characterized by a severe, self-imposed weight loss ranging from 10% to 50% of premorbid weight, which typically was normal or not more than 5 lb (2.3 kg) over ideal weight. Related findings include skeletal muscle atrophy, loss of fatty tissue, hypotension, constipation, dental caries, susceptibility to infection, blotchy or sallow skin, cold intolerance, hairiness on the face and body, dryness or loss of scalp hair, and amenorrhea. The patient usually demonstrates restless activity and vigor and may also have a morbid fear of becoming fat. Self-induced vomiting or use of laxatives or diuretics may lead to dehydration or to metabolic alkalosis or acidosis.

Cancer.Weight loss is often a sign of cancer. Other findings reflect the type, location, and stage of the tumor and can include fatigue, pain, nausea, vomiting, anorexia, abnormal bleeding, and a palpable mass.

Crohn's disease.With Crohn's disease, weight loss occurs with chronic cramping, abdominal pain, and anorexia. Other signs and symptoms include diarrhea, nausea, fever, tachycardia, abdominal tenderness and guarding, hyperactive bowel sounds, abdominal distention, and pain. Perianal lesions and a palpable mass in the right or left lower quadrant may also be present.

Cryptosporidiosis.Weight loss may occur with cryptosporidiosis. Other findings include profuse watery diarrhea, abdominal cramping, flatulence, anorexia, malaise, fever, nausea, vomiting, and myalgia.

Depression.Weight loss or weight gain may occur with severe depression, along with insomnia or hypersomnia, anorexia, apathy, fatigue, and feelings of worthlessness. Indecisiveness, incoherence, and suicidal thoughts or behavior may also occur.

Diabetes mellitus.Weight loss may occur with diabetes mellitus, despite increased appetite. Other findings include polydipsia, weakness, fatigue, and polyuria with nocturia.

Esophagitis.Painful inflammation of the esophagus leads to temporary avoidance of eating and subsequent weight loss. Intense pain in the mouth and anterior chest occurs, along with hypersalivation, dysphagia, tachypnea, and hematemesis. If a stricture develops, dysphagia and weight loss will recur.

Gastroenteritis.Malabsorption and dehydration cause weight loss in gastroenteritis. The loss may be sudden in acute viral infections or reactions or gradual in parasitic infection. Other findings include poor skin turgor, dry mucous membranes, tachycardia, hypotension, diarrhea, abdominal pain and tenderness, hyperactive bowel sounds, nausea, vomiting, fever, and malaise.

Leukemia.Acute leukemia causes progressive weight loss accompanied by severe prostration; high fever; swollen, bleeding gums; and bleeding tendencies. Dyspnea, tachycardia, palpitations, and abdominal or bone pain may occur. As the disease progresses, neurologic symptoms may eventually develop.

Chronic leukemia causes progressive weight loss with malaise, fatigue, pallor, enlarged spleen, bleeding tendencies, anemia, skin eruptions, anorexia, and fever.

Lymphoma.Hodgkin's disease and non-Hodgkin's lymphoma cause gradual weight loss. Associated findings include fever, fatigue, night sweats, malaise, hepatosplenomegaly, and lymphadenopathy. Scaly rashes and pruritus may develop.

Pulmonary tuberculosis.Pulmonary tuberculosis causes gradual weight loss, along with fatigue, weakness, anorexia, night sweats, and low-grade fever. Other clinical effects include a cough with bloody or mucopurulent sputum, dyspnea, and pleuritic chest pain. Examination may reveal dullness on percussion, crackles after coughing, increased tactile fremitus, and amphoric breath sounds.

Stomatitis.Inflammation of the oral mucosa (usually red, swollen, and ulcerated) in stomatitis causes weight loss due to decreased eating. Associated findings include fever, increased salivation, malaise, mouth pain, anorexia, and swollen, bleeding gums.

Thyrotoxicosis.With thyrotoxicosis, increased metabolism causes weight loss. Other characteristic signs and symptoms include nervousness, heat intolerance, diarrhea, increased appetite, palpitations, tachycardia, diaphoresis, fine tremor and, possibly, an enlarged thyroid and exophthalmos. A ventricular or atrial gallop may be heard.

Other causes

Drugs.Amphetamines and inappropriate dosage of thyroid preparations commonly lead to weight loss. Laxative abuse may cause a malabsorptive state that leads to weight loss. Chemotherapeutic agents cause stomatitis or nausea and vomiting, which, when severe, causes weight loss.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Goiter: Goiter - etiology
(The 5-Minute Pediatric Consult)

• The multinodular goiter 1 (MNG1) locus has been identified on chromosome 14q and on chromosome Xp22.
• Other genes implicated in simple goiter formation include thyroglobulin, thyroid-stimulating hormone (TSH) receptor, and Na⁺/I^- symporter.
• Thyroid peroxidase mutations lead to iodide organification defects and goitrous congenital hypothyroidism.
• Twin and family studies show a modest to major contribution of environmental factors, especially iodine deficiency and cigarette smoking.
• Autoimmune goiters, such as chronic lymphocytic thyroiditis, occur in children with a genetic predisposition.
• Thyroid cancers are usually sporadic. Medullary carcinoma can be familial (autosomal dominant), as part of multiple endocrine neoplasia (MEN)-2A and -2B, or as isolated malignancy.
• Pendred syndrome (autosomal recessive) causes congenital sensorineural deafness and iodine organification defect that leads to goiter.

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

 » Next page: Risk Factors for Hyperthyroidism

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