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Diagnostic Tests for Hyperthyroidism

Contents
  1. Hyperthyroidism: Introduction
  2. Tests for Hyperthyroidism
  3. Symptoms of Hyperthyroidism
  4. Diagnosis
  5. Home Diagnostic Testing
  6. Failure to Diagnose
  7. Alternative Diagnoses
  8. Misdiagnosis
  9. Complications

Hyperthyroidism: Diagnostic Tests

The list of diagnostic tests mentioned in various sources as used in the diagnosis of Hyperthyroidism includes:

  • Thyroid hormone blood tests
  • X-ray scan - to detect any tumors
  • CAT scan - to detect any tumors
  • MRI scan - to detect any tumors

Hyperthyroidism Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Hyperthyroidism:

Hyperthyroidism Diagnosis: Book Excerpts

Diagnosis of Hyperthyroidism: medical news summaries:

The following medical news items are relevant to diagnosis of Hyperthyroidism:

Diagnostic Tests for Hyperthyroidism: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Hyperthyroidism.

EXOPHTHALMOS: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

THYROID ENLARGEMENT: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine tests include a CBC, sedimentation rate, urinalysis, thyroid profile with a TSH immunoassay, chemistry panel, chest x-ray, and EKG. Thyroid antibodies may be tested if Hashimoto's thyroiditis is suspected.

The most important study is a thyroid technetium-99m or iodine-123 uptake and scan. If the results of these are abnormal, then an endocrinologist or general surgeon should be consulted to assist in the interpretation. If the scan indicates a cold nodule, ultrasonography may be done to determine whether the nodule is cystic or solid. If it is cystic, generally it can be aspirated and followed. If it is solid, a biopsy or aspiration and biopsy should be undertaken. If there are malignant cells or at least suspicious cells for malignancy, surgery should be done. If the scan reveals a hot nodule and there is clinical and laboratory evidence of thyrotoxicosis, the patient should be treated with radioactive iodine or surgery. If the scan shows diffuse uptake of radioactive materials and there is clinical thyrotoxicosis, the patient also may be treated with radioactive iodine or surgery.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

WEIGHT LOSS: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid panel, serum amylase and lipase, febrile agglutinins, tuberculin test, ANA titer, serum protein electrophoresis, serum B 12 and folic acid, chest x-ray, EKG, and a flat plate of the abdomen. An HIV antibody titer needs to be done in selected clinical circumstances.

A stool for fat, trypsin, occult blood, and ovum and parasites should be done. Further tests for steatorrhea are listed on page 446 . If these tests are within normal limits or are unrevealing, it is best to refer the patient to a gastroenterologist or oncologist for further evaluation. Sometimes, clinical clues suggest the need for an endocrinologist or psychiatrist as well. However, if the primary care physician wishes to proceed further, he may order an upper GI series and esophagogram, a small bowel series, barium enema, and a sigmoidoscopic examination. A CT scan of the abdomen and pelvis may be useful, but it is an expensive procedure.

Twenty-four-hr urine collection for 17-ketosteroids and 17-hydroxysteroids or rapid ACTH stimulation test will diagnose Addison's disease. Quantitative stool fat and d -xylose absorption or a simple glucose tolerance test will diagnose some cases of malabsorption syndrome. Endoscopic procedures, including laparoscopy and even an exploratory laparotomy, have their place in the diagnostic workup. However, it is always best to enlist the help of specialists before considering these procedures, even if one is located in an isolated community.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

» READ BOOK EXCERPT ONLINE »

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

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

The patient’s history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, onset of thyroid enlargement, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.

Begin the physical examination by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you’ll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient’s neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.

During palpation, be sure to note the size, shape, and consistency of the gland, and the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit. The bruit is often continuous.

» READ BOOK EXCERPT ONLINE »

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

Weight gain, excessive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced visual disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?

Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?

During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status, pages 644 and 645.) Note fat distribution and the presence of localized or generalized edema and overall nutritional status. Inspect for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient’s vital signs.

» READ BOOK EXCERPT ONLINE »

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

Low birth weight: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 382 and 383.) Follow with a routine neonatal examination.

» READ BOOK EXCERPT ONLINE »

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

Weight loss, excessive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin with a thorough diet history because weight loss almost always is caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask him about previous weight and if the recent loss was intentional. Be alert to lifestyle or occupational changes that may be a source of anxiety or depression. For example, has he gotten separated or divorced? Has a family member or friend died recently? Has he recently changed jobs?

Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially any use of diet pills and laxatives.

Carefully check the patient’s height and weight, and ask about his previous weight. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident? Ask about exact weight changes (with approximate dates).

Next, examine the patient’s skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth, and note any hyperpigmentation of the buccal mucosa. Also, check the patient’s eyes for exophthalmos and his neck for swelling; evaluate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.

Conventional laboratory and radiologic investigations such as complete blood count, serum albumin levels, urinalysis, chest X-ray, and upper GI series usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.

» READ BOOK EXCERPT ONLINE »

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

Thyroid enlargement: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

The patient’s history commonly reveals the cause of thyroid enlargement. Important data include a family history of thyroid disease, when the thyroid enlargement began, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.

Begin the physical examination by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you’ll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient’s neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.

During palpation, be sure to note the size, shape, and consistency of the gland as well as the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit, which is commonly continuous.

» READ BOOK EXCERPT ONLINE »

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

Weight gain, excessive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced visual disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?

Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?

During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status.) Note fat distribution, the presence of localized or generalized edema, and overall nutritional status. Examine the patient for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient’s vital signs.

» READ BOOK EXCERPT ONLINE »

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

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

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

» READ BOOK EXCERPT ONLINE »

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

Low birth weight: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 488 and 489.) Follow with a routine neonatal examination.

» READ BOOK EXCERPT ONLINE »

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

Weight loss, excessive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin with a thorough diet history because weight loss is almost always caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask about his previous weight and whether the recent loss was intentional. Be alert for lifestyle or occupational changes that may be causing anxiety or depression. For example, has he gotten separated or divorced? Has he recently changed jobs?

Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially the use of diet pills or laxatives.

Carefully check the patient’s height and weight, and ask about exact weight changes with approximate dates. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident?

Next, examine the patient’s skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth, and note any hyperpigmentation of the buccal mucosa. Also, check the patient’s eyes for exophthalmos and his neck for swelling; auscultate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.

Conventional laboratory and radiologic tests, such as complete blood count, serum albumin levels, urinalysis, chest
X-rays, and upper GI series, usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.

» READ BOOK EXCERPT ONLINE »

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

Weight Loss: Basic physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Relevant physical findings will be present in 66% of cases (1,2,5).

B. Quantify loss by serial weight measurements.

C. Check the vital signs: temperature, blood pressure, and respiratory and heart rates. Consider determining oxygen saturation.

D. Perform a physical examination, with emphasis on areas suggested by clues from the history.

Testing

A. Basic laboratory tests. Debate continues regarding the most useful and cost-effective laboratory testing for involuntary weight loss. A structured approach is best (1–5). Useful tests include:

1. Complete blood count, thyrotropin assay, urinalysis, and fecal occult blood testing.

 2. Comprehensive chemistry panel including albumin, transaminases, blood urea nitrogen, creatinine, and electrolytes—calcium, magnesium, phosphorus, sodium, and potassium.

 3. Chest radiograph is often useful but not required (1).

B. Comprehensive analysis. Further testing should be done only as directed by the initial findings. Careful observation and follow-up are superior management strategies to undirected diagnostic testing (1–5).

1. When indicated, upper gastrointestinal radiographs, endoscopy, and colonoscopy are the most useful second-line tests (3).

 2. National Cancer Institute or United States Preventive Services Task Force age-specific screening guidelines should be considered and brought up to date for the patient. These can be accessed on the internet through the National Library of Medicine (http://www.nlm.nih.gov).

 3. Computed tomography and other expensive investigations are seldom beneficial in the absence of a specific (often guideline-based) indication (3,4).

Diagnostic assessment.

 The integration of history, examination, and laboratory data usually reveals the cause for involuntary weight loss.

 A. Cancer, including gastrointestinal malignancies, accounts for 16% to 36% of cases, and other gastrointestinal diseases account for another 14% to 23% (1,3).

 B. If the initial steps are not conclusive, the best approach is careful observation. Follow-up examinations and testing should be done monthly for 6 months. If a physical cause exists, it will almost always be found within this time (1).

 C. If an organic cause is present, this simple approach will find it more than 75% of the time (1–3).

D. If an organic cause is not identified in 6 months, one is unlikely to be found (1–3). These undifferentiated patients, however, do well and have an excellent prognosis, assuming they do not have continued and progressive weight loss (1).

E. Malignancy is a significant cause of weight loss; however, a truly occult malignancy is rare and an exhaustive search for one is not supported by the literature (1–5).


References

1. Marton KI, Sox Jr HC, Krupp JR. Involuntary weight loss: diagnostic and prognostic significance. Ann Intern Med 1981;95:568–574.

2. Rabinovitz M, Pitlik SD, Leifer M, et al. Unintentional weight loss. A retrospective analysis of 154 cases. Arch Intern Med 1986;146:186–187.

3. Thompson MP, Morris LK. Unexplained weight loss in the ambulatory elderly. J Am Geriatr Soc 1991;39:497–500.

4. Wise GR, Craig D. Evaluation of involuntary weight loss. Where do you start? Postgrad Med 1994;95:143–146, 149–150.

5. Reife CM. Involuntary weight loss. Med Clin  North Am 1995;79(2):299–313.

» READ BOOK EXCERPT ONLINE »

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

Thyrotoxicosis/Hyperthyroidism: Physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Observation. Clothing may be loose because of weight loss. Clothing choices may suggest inappropriate heat intolerance, whereas the welcoming handshake may present warm moist hands with a fine tremor. Other possible observations include nervousness or restlessness, a characteristic stare with widened palpebral fissures, lid lag and infrequent blinking, and silky fine hair.

 B. General examination. Vital sign abnormalities commonly include weight loss, sinus tachycardia, arrhythmias, and systolic hypertension with a widened pulse pressure. Systolic murmurs, cardiac enlargement, and, occasionally, overt heart failure may be found on cardiovascular examination (Chapters 7.4, 7.5 and 7.7). Besides the classic stare noted above, Graves’ disease can also present with proptosis (which may be asymmetric), ophthalmoplegia (with impaired conjugate eye movement and strabismus), orbital congestion (with periorbital edema and potential compression of the optic nerve), and inflammation of the conjunctiva and cornea. Pretibial myxedema, an unusual but pathognomonic finding in Graves’disease, is a painless raised thickening of the subcutaneous tissue, most often found in the anterior lower leg or dorsal foot. It produces a peau d’orange texture, which can be pruritic and hyperpigmented. Clubbing of the fingers and toes is also found in Graves’disease, but is very rare. An ovarian mass, usually unilateral, may indicate struma ovarii. Thyrotoxicosis (but not hyperthyroidism) can result from this teratoma, which infrequently produces thyroid hormone.

 C. Thyroid examination. Inspect the neck below the thyroid cartilage from the front and side. During palpation, approach the patient from the front or from behind and palpate using the fingers or thumbs. Having the patient swallow during both inspection and palpation causes the thyroid to move and aids in developing a three-dimensional impression of the gland. The size, consistency, and tenderness of the gland are important, as are the presence and characteristics of any nodules. Auscultation of a bruit over the gland correlates with increased vascularity, usually indicative of Graves’disease.

Testing

 A. Laboratory testing. A sensitive assay for thyroid-stimulating hormone (sTSH) is the best test for detecting thyrotoxicosis. Thyrotoxicosis from any cause, except the extremely rare instance of excess TSH production, results in a suppressed sTSH. Thyrotoxicosis is confirmed by an elevated free thyroxine index (FTI) or an elevated free thyroxine (fT4), measured directly. If the FTI or fT4 is normal, T3 should be measured to evaluate for T3 toxicosis. Assays for thyroid autoantibodies, including TSH receptor antibodies, are usually not required. However, they can be helpful in selected cases (e.g., pregnancy, where levels correlate with risk to the fetus).

 B. Diagnostic imaging. Radioactive iodine uptake (RAIU) can help clarify the cause of thyrotoxicosis. A diffuse increase in RAIU is consistent with Graves’ disease, whereas nodular concentration is consistent with toxic adenoma (a single increased area) or multinodular goiter (multiple areas of increased uptake) (3). A decrease in RAIU is consistent with exogenous (iatrogenic or factitious) thyrotoxicosis, thyroiditis, iodine-induced thyrotoxicosis, or struma ovarii.

Diagnostic assessment

 Accurate diagnosis depends on the appropriate combination and interpretation of history, PE, and testing.

A. Graves’ disease. If ophthalmopathy is present, the diagnosis of Graves’ disease is usually obvious. Typically, the thyroid gland is increased in size, smooth, and nontender. A bruit is present in 50% of patients. The RAIU is homogeneously increased and pretibial myxedema may be present.

B. Toxic nodular goiter is the most common cause of thyrotoxicosis in those aged more than 40 years. The thyroid gland is typically increased in size, nontender, but with multiple nodules. The RAIU is increased in a heterogeneous pattern. A single toxic nodule is more common in younger people and has the RAIU concentrated in one spot, with suppression of the remaining gland.

C. Exogenous (iatrogenic or factitious) thyrotoxicosis is associated with a gland that is small or normal sized and a low or absent RAIU. A psychiatric evaluation should be considered in factitious thyrotoxicosis.

 D. Thyroiditis. Thyrotoxicosis can be produced as hormone leaks from an inflamed gland. Typically, the symptoms of the diverse thyroiditis entities are of recent onset and have escalated rapidly. The gland is enlarged and either tender (subacute thyroiditis) or nontender (painless thyroiditis or postpartum thyroiditis). RAIU is very low or absent. Transient hypothyroidism often follows as the intrathyroidal stores of hormone are depleted. Acute suppurative thyroiditis is a rare infectious disorder, usually caused by pyogenic organisms (5).

 E. Other diagnoses. Thyrotoxicosis with hyperthyroidism and an inappropriately elevated sTSH suggests a TSH-secreting pituitary tumor. Thyrotoxicosis without hyperthyroidism and an increased RAIU over the pelvis suggests struma ovarii. A low sTSH with normal T3 and FTI or fT4 indicates subclinical hyperthyroidism or TSH suppression by nonthyroidal factors (e.g., corticosteroid administration or starvation).


References

1. Helfand M, Redfern CC. Screening for thyroid disease: an update. Ann Intern Med 1998;129:144–158.

2. Hennessey JV. Diagnosis and management of thyrotoxicosis. Am Fam Physician 1996;54:1315–1324.

3. Thyroid Guidelines Task Force of the American Association of Clinical Endocrinologists and the American College of Endocrinology. AACE Clinical Practice Guidelines for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism. Endocrine Prac 1995;1:54–62.

4. Trivalle C, Doucet J, Chassagne P, et al. Differences in the signs and symptoms of hyperthyroidism in older and younger patients. J Am Geriatr Soc 1996;44:50–53.

5. Sakiyama R. Thyroiditis: a clinical review. Am Fam Physician 1993;48:615–621.

» READ BOOK EXCERPT ONLINE »

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

Thyroid Enlargement/Goiter: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. General examination. Look for typical vital and physical signs consistent with hypothyroidism or thyrotoxicosis. Pemberton’s sign can be induced by having the patient raise both arms above the head.

B. Thyroid examination. Inspect the neck below the thyroid cartilage from the front, using cross-lighting to accentuate shadows and masses. Full extension of the neck enhances visibility of the gland. Inspection from the side with measurement of any prominence of the normally smooth and straight contour between the cricoid cartilage and the suprasternal notch is useful. Palpitation is done using the technique with which the examiner is most experienced and skilled. Approach the patient from either the front or behind and palpate using the fingers or thumbs. If felt between the cricoid cartilage and the suprasternal notch, the thyroid isthmus can be used to help locate the gland. Palpation of the lobes can be improved by relaxation of the sternocleidomastoid; for example, the left lobe can be defined better by having the patient slightly flex and rotate the neck to the left. Other useful maneuvers include measuring the circumference of the neck or the dimensions of each lobe. Note the location, size, consistency, mobility, and tenderness of any nodules. Having the patient swallow during both inspection and palpation causes the thyroid to move and aids in developing a three-dimensional impression of gland shape and size. This maneuver can also make a low-placed gland accessible. Categorize thyroid size as “normal” or “goiter,” and subcategorize “goiter” as “small” (two or less times normal) or “large” (more than two times normal) (2).

Testing

 A. Laboratory testing. The sensitive TSH (sTSH) assay is the single best test to evaluate thyroid status. Elevated sTSH is highly suggestive of hypothyroidism (Chapter 14.4). If sTSH is suppressed, an elevated free thyroxine index (FTI) or free thyroxine (fT4) measured directly, confirms thyrotoxicosis (Chapter 14.8). In a patient with a suppressed sTSH and a normal FTI or fT4, serum triiodothyronine (T3) should be measured to assess for possible T3 thyrotoxicosis.

B. Diagnostic imaging. Nuclear scans and ultrasound studies are not warranted in the routine evaluation of simple or multinodular goiter (4). Ultrasonography may be helpful in patients with equivocal findings on palpation. Symptoms suggestive of substernal mechanical pressure require evaluation, usually by computed tomography (CT) or magnetic resonance imaging (MRI).

 C. Other tests. Fine needle aspiration biopsy (FNAB) should be performed in cases of a solitary or dominant nodule found by palpation. Pulmonary function tests are warranted with evidence of inspiratory impairment. Barium swallow is indicated to evaluate goiter-associated dysphagia.

Diagnostic assessment

 The evaluation of goiter focuses on the history, thyroid palpation, and functional status of the gland. An asymptomatic patient with a simple or multinodular goiter associated with a normal metabolic state does not necessarily require further diagnostic studies or treatment. Periodic assessment, at least annually, to evaluate growth, function, and symptoms is warranted. A palpable solitary nodule or dominant nodule in a multinodular gland should be evaluated by FNAB or excisional biopsy (Chapter 14.7). Goiter with compressive symptoms requires CT or MRI evaluation and referral for probable surgery. Further assess a goiter associated with an abnormal metabolic state as outlined for hypothyroidism (Chapter 14.4) or thyrotoxicosis (Chapter 14.8). Thyroid hormone suppression of any goiter type is controversial, and the risks associated with subclinical hyperthyroidism must be included in the risk-to-benefit analysis (5).


References

1. Petrone LR. A primary care approach to the adult patient with nodular thyroid disease. Arch Fam Med 1996;5:92–100.

2. Siminoski K. Does this patient have a goiter? JAMA 1995;273:813–817.

3. Peter HJ, Burgi U, Gerber H. Pathogenesis of nontoxic diffuse and nodular goiter. In: Braverman LE, Utiger RD, eds. Werner and Ingbar’s the thyroid, 7th ed. Philadelphia: JB Lippincott, 1996:890–895.

4. Tan GH, Gharib H. Thyroid nodular disease: diagnostic evaluation and management [Letter]. Arch Intern Med 1997;157:575.

5. Gharib H, Mazzaferri EL. Thyroxine suppressive therapy in patients with nodular thyroid disease. Ann Intern Med 1998;128:386–394.

» READ BOOK EXCERPT ONLINE »

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

Involuntary Weight Loss: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Cachexia is accelerated loss of lean body mass in the context of a chronic inflammatory response, caused by a combination of decreased intake (with decreased appetite) and increased metabolic rate. The cause of the weight loss will usually be evident, based on concurrent symptoms. If not, first document that weight loss has occurred by using prior records of measured weights or the discovery of loose-fitting clothes (tightening belt notches) or dentures. If the cause is not found on the first pass, document the weight and re-examine several weeks later.

Weight loss in patients with congestive heart failure, cirrhosis, and
uremia may be masked by fluid retention, but temporalis and limb wasting will be prominent. Weight loss in malignancy of more than 5% of body mass prior to treatment portends a poor prognosis.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Neck Mass/Thyroid Enlargement: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Patients often present for evaluation of a “neck mass” that is a normal structure such as the hyoid, and they will insist that it is new or asymmetric.

With thyroid enlargement, the mass will be low in the neck and extend across the midline. Occasionally, a prominent thyroid nodule will mimic a lymph node but is in an atypical location. The thyroid gland rises and falls with swallowing. The only other structure to do this is a thyroglossal duct cyst.

In a multinodular goiter, a malignancy should be suspected when there is a dominant nodule or cervical adenopathy.

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Source: Field Guide to Bedside Diagnosis, 2007

Exophthalmos: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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

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

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Source: Field Guide to Bedside Diagnosis, 2007

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

Begin the assessment by taking the patient’s vital signs, noting fever, which may accompany eye infection. Next, evaluate the severity of exophthalmos with an exophthalmometer. (See Detecting unilateral exophthalmos.) If the eyes bulge severely, look for cloudiness on the cornea, which may indicate ulcer formation. Describe any eye discharge and observe for ptosis. Then check visual acuity, with and without correction, and evaluate extraocular movements. Palpate the patient’s thyroid for enlargement or goiter.

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

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

Begin the physical assessment by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. (See Palpating the thyroid gland, page 650.)

During palpation, be sure to note the size, shape, and consistency of the gland, and the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit. The bruit is usually continuous.

» READ BOOK EXCERPT ONLINE »

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

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

During your physical assessment, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status, pages 710 and 711.) Note fat distribution and the presence of localized or generalized edema and overall nutritional status. Inspect for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient’s vital signs.

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

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

Carefully check the patient’s height and weight. Ask about his previous weight. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident? Ask about exact weight changes (with approximate dates).

Next, examine the patient’s skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth, and note any hyperpigmentation of the buccal mucosa. Also check the patient’s eyes for exophthalmos and his neck for swelling; evaluate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.

Conventional laboratory and radiologic investigations, such as complete blood count, serum albumin levels, urinalysis, chest X-ray, and upper GI series usually reveal the cause of weight loss.

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

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

  • Determinewhether problem is primarily one of impaired weight gain, lineargrowth, or combination.
  • Complete history and physical examshould be performed.
  • Growth parameters (weight, height,head circumference) should be plotted on growth charts publishedby CDC (2001). All past measurements should also be plotted on thesegrowth curves.

    • Impaired Weight Gain or Weight Loss

  • Diagnosisof intrauterine growth disturbance can be made at birth or evensometimes before birth.
  • History and physical exam provide theclues for further investigation.
  • Presence of dysmorphic features andabnormal physical findings suggests chromosomal disorders, dysmorphicsyndromes, or multiple malformation syndromes of unknown cause.
  • Chromosomal karyotype with bandingtechniques should be performed with suspected chromosomal disorder,with unknown constellation of dysmorphic features, or with majorand minor malformations.
  • Presence of specific major malformation(e.g., hydrocephalus) determines which further diagnostic testsneed to be performed.
  • If problem is primarily weight gain,history can estimate daily caloric intake. This and other historicinformation along with physical exam is diagnostic in many casesincluding psychologic disturbances.
  • Inadequate caloric intake is most commoncause of failure to gain weight in otherwise normal child. Withproper counseling and follow-up, mild cases may be treated successfullywithout hospitalization. If child is ill or lack of weight gainis more than mild or psychosocial problems are serious, he or shecan be admitted to the hospital to monitor caloric intake and weightgain, gain more insight and understanding about parents and family,and educate parents about proper nutrition.
  • Excessive caloric wasting from persistentdiarrhea, polyuria, or vomiting can impair adequate weight gainand also cause weight loss. See Chap.14, Diarrhea; Chap.47, Polyuria and Polydipsia; and Chap. 55, Regurgitation and Vomiting,respectively.
  • Best screening tests for chronic diseaseare history and physical exam. Tests that can help pinpoint theinvolved organ system include CBC with differential; stool guaiac;serum electrolytes, glucose, creatinine, calcium, and phosphorus;blood urea nitrogen; UA; urine culture; erythrocyte sedimentationrate; liver function tests; chest radiography; sweat test; and endomesial antibodies.

    • Impaired Skeletal Growth (Height)

  • Same generaldiagnostic approach described for impaired weight gain should befollowed in cases of impaired linear growth.
  • Weight, height, and head circumferencemeasurements should be recorded on standard growth charts. Lengthis usually measured from birth until 18 mos of age, whereas heightis commonly measured after this age.
  • Height velocity charts of Tanner andDavies (1985) can be used to calculate height velocity in cm/yr.
  • Most common causes of short statureinclude genetic (familial) short stature, constitutional delay,chronic disease of any organ system, and psychosocial deprivation.
  • In general, diagnostic studies arelimited to short children who are growing at subnormal rate. Ifgrowth rate is normal, significant problem is unlikely.
  • If history and physical exam do notidentify cause of abnormal growth, certain tests should be considered:CBC with differential; UA including pH and specific gravity; urineculture; erythrocyte sedimentation rate; serum electrolytes, glucose,and creatinine; blood urea nitrogen; T4 andTSH; insulin-like growth factor-binding protein 3 and insulin-likegrowth factor I; and bone age.
  • Bone age measurement provides assessmentof skeletal maturation as index of biologic age. Can be determinedby using knee radiograph in infants <3 mos of age and lefthand and wrist in those >3 mos of age and should be performedwith suspected growth hormone deficiency.
  • Other tests depend on results of theabove findings and suspected diagnosis.
  • When disproportionate growth is clinicallyobserved, ratio of upper to lower segment may be useful. Lower segmentis measured from pubis to bottom of feet, and this measurement issubtracted from height to give upper segment length. Normal uppersegment:lower segment ratio is 1.7:1 at birth and decreases untilabout age 10 yrs, when it is 1, which approximates normal adultvalue. Disproportionate short limbs or trunk are noted with manyof the osteochondrodysplasias.
  • Genetic growth potential can be estimatedby the following procedure as noted by Rudolph (1996). Based ongenetic factors alone, predicted adult height should fall within5 cm above or below calculated midparental height. Midparental heightfor girls is calculated as follows: [(father'sheight - 13 cm) + (mother's height)] dividedby 2. Midparental height for boys is calculated as follows: [(mother'sheight + 13 cm) + (father's height)] dividedby 2.
    • >

    » READ BOOK EXCERPT ONLINE »

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

    Thyroid enlargement: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    The patient's history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, onset of thyroid enlargement, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.

    Begin the physical examination by inspecting the patient's trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you'll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient's neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.

    During palpation, be sure to note the size, shape, and consistency of the gland, and the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit. The bruit is often continuous.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Weight gain, excessive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Determine your patient's previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Ask about associated symptoms. Has the patient experienced vision disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation? Is she menopausal or postmenopausal?

    Form an impression of the patient's mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he taking?

    During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status, pages 644 and 645.) Note fat distribution and the presence of localized or generalized edema and overall nutritional status. Inspect for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient's vital signs.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Low birth weight: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    As soon as possible, evaluate the neonate's neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age.) Follow with a routine neonatal examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Weight loss, excessive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin with a thorough diet history because weight loss is almost always caused by inadequate caloric intake. If the patient hasn't been eating properly, try to determine why. Ask him about previous weight and whether the recent loss was intentional. Determine how long the weight loss has been taking place. Be alert to lifestyle or occupational changes that may be a source of anxiety or depression. Has the patient recently experienced a loss?

    Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Has he been experiencing other pain? If so, ask about the location of the pain and how long he has had it. Take a careful drug history, noting especially use of diet pills and laxatives.

    Carefully check the patient's height and weight and ask about his previous weight. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident? Ask about exact weight changes (with approximate dates).

    Examine the patient's skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth and note hyperpigmentation of the buccal mucosa. Check the patient's eyes for exophthalmos and his neck for swelling; evaluate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.

    Conventional laboratory and radiologic investigations such as complete blood count, serum albumin levels, urinalysis, chest X-ray, and upper GI series usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Hyperthyroidism

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