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Diseases » Hypoparathyroidism » Diagnosis
 

Diagnosis of Hypoparathyroidism

Diagnostic Test list for Hypoparathyroidism:

The list of medical tests mentioned in various sources as used in the diagnosis of Hypoparathyroidism includes:

  • Blood phosphate level
  • Blood calcium level

Hypoparathyroidism Diagnosis: Book Excerpts

Diagnostic Tests for Hypoparathyroidism: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Hypoparathyroidism.


HYPOCALCEMIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. What is the PTH assay? If this is low, hypoparathyroidism ought to be considered the most likely diagnosis. If it is normal or increased, other causes of hypocalcemia should be investigated.
  2. What is the phosphorus level? A decreased phosphorus level should prompt a search for malabsorption syndrome, rickets, osteomalacia, renal tubular acidosis, cirrhosis, and nephrotic syndrome. An elevated phosphorus level would be most suggestive of renal disease, but pseudohypoparathyroidism must be considered also.
  3. What is the alkaline phosphatase level? This would be elevated in hypocalcemia due to malabsorption syndrome, rickets, osteomalacia, renal tubular acidosis, and other chronic renal disease. It would be normal in cirrhosis, nephrosis, alkalosis, and pseudohypoparathyroidism.

DIAGNOSTIC WORKUP

CBC, urinalysis, chemistry panel, 24-hr urine calcium, PTH assay, serum protein electrophoresis, serum 25-OH vitamin D3 , skeletal survey, bone scan, d -xylose absorption test, serum 1,25-(OH) 2 vitamin D, and an endocrinology consult should be considered in the workup. Pseudohypoparathyroidism can be further differentiated from primary hypoparathyroidism by the Ellsworth-Howard test, which involves injecting parathyroid hormone intravenously. The blood values of calcium and phosphorus will improve in primary hypoparathyroidism but remain the same in pseudohypoparathyroidism. There is a phosphate diuresis in primary hypoparathyroidism.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

THYROID ENLARGEMENT: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it focal or diffuse? Focal masses in the thyroid include thyroglossal cyst, toxic adenoma, colloid cyst, Riedel's struma, nontoxic adenoma, and malignancies.
  2. Is there movement with protrusion of the tongue? This is a typical finding in cases of thyroglossal cyst.
  3. If focal, are there signs of thyrotoxicosis? The presence of thyrotoxicosis and a focal mass suggest toxic adenoma.
  4. If diffuse, are there signs of thyrotoxicosis? Diffuse thyroid enlargement with thyrotoxicosis indicates Graves' disease.
  5. Is it tender? The presence of a tender enlarged thyroid suggests subacute thyroiditis and Hashimoto's thyroiditis.

DIAGNOSTIC WORKUP

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

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

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Hypocalcemia: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Hypoalbuminemia commonly results in a “pseudohypocalcemia”
    –Results in decreased total serum Ca2+ but normal free, ionized (active) Ca2+
    –Does not result in sequelae of hypocalcemia
    • Hypoparathyroidism
      –Often occurs after thyroidectomy or parathyoidectomy
      –Infiltrative diseases of the parathyroid gland (e.g., hemochromatosis, Wilson's disease, sarcoidosis, tuberculosis)
      –Pseudohypoparathyroidism (parathyroid hormone resistance)
      –Idiopathic (autoimmune)
    • Medications (e.g., diuretics, heparin, foscarnet, cimetidine, glucagon, phosphates, aminoglycosides, theophylline, cisplatin)
    • Vitamin D deficiency
      –Poor oral intake and/or absent sun exposure
      –Malabsorption
      –Hepatic and/or renal failure
      –Anticonvulsant use
    • Pancreatitis
    • Alkalosis (especially respiratory alkalosis)
    • Sepsis
    • Shock
    • Burns
    • Magnesium deficiency (often seen in alcoholism)
    • Hyperphosphatemia
    • Alcoholism (may directly suppress PTH and/or deplete magnesium)
    • Postoperative (usually transient)
    • Post-blood transfusion
    • Malignancy
      –Medullary carcinoma of the thyroid
      –Osteoblastic metastases
    • Familial hypocalcemia
    • DiGeorge's syndrome (congenital absence of the parathyroid glands)
    • Polyglandular autoimmune syndrome, type I (hypoparathyroidism, adrenal insufficiency, and mucocutaneous candidiasis)
    • Rickets

    Workup and Diagnosis

    • History and physical examination
      –Severity of symptoms depends on rapidity of fall in serum calcium
      –Symptoms include weakness, fatigue, muscle cramping and spasm (difficulty speaking may indicate laryngeal spasm), paresthesias (perioral or fingertip), abdominal pain, nausea/vomiting, irritability, and depression
      –Severe hypocalcemia may cause delirium, psychosis, and seizures
      –Skin exam may reveal patchy hair loss, dry and/or scaly skin, hyperpigmentation, brittle nails, and mucocutaneous candidiasis
      –Trousseau's sign: Carpal spasms upon inflation of a blood pressure cuff for 2 to 3 minutes
      –Chvostek's sign: Tapping of cranial nerve VII (anterior to ear) causes twitching of facial muscles
      –Cardiac arrhythmias, decreased myocardial contractility (may lead to CHF), hypotension
    • Initial labs include serum calcium, ionized calcium, albumin, magnesium, phosphorus, BUN/creatinine, CBC, and amylase/lipase
    • Correct calcium for hypoalbuminemia: Serum Ca2+ decreases by 0.8 for each 1 g/dL drop in albumin (although ionized calcium is normal)
    • Measure parathyroid hormone and vitamin D levels
      –Decreased in primary hypoparathyroidism
      –Elevated in renal failure, malabsorption, vitamin D deficiency, and pseudohypoparathyroidism
    • ECG may reveal prolonged QT interval

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

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

    • Hypoparathyroidism
      –Congenital: Transient neonatal vs heritable forms
      –Acquired: Autoimmune, postsurgical, radioablation, infiltrative
      –DiGeorge Syndrome
      –Polyglandular autoimmune disease type 1 (Blizzard syndrome)
      –Pseudohypoparathyroidism (PHP) or PTH resistance
            –PHP type IA (Albright dereditary osteodystrophy)
            –PHP type IB, type II
    • Vitamin D deficiency
      –Nutritional deprivation
            –Most common cause of rickets
            –Seen in breast-fed and black children
      –Malabsorption/steatorrhea/liver disease
      –1-αhydroxylase deficiency
      –Chronic renal disease
    • Calcium deficiency
      –Nutritional deprivation
      –Malabsorption
      –Hypercalciuria
      • Hypomagnesemia
        –Impairs secretion of, and end-organ responsiveness to, PTH
        –Inherited forms
        –Intestinal losses
        –Renal wasting: RTA, drugs
    • Hyperphosphatemia
      • Hypoproteinemia
        –Total calcium is a measure of calcium bound to albumin
      • Drugs
        –Loop diuretics (furosemide) promote renal calcium excretion
        –Anticonvulsants interfere with GI vitamin D absorption
        –Antacids impair GI calcium absorption
        –Antineoplastic agents
        –Citrated blood products
    • Critical illness
      –Rhabdomyolysis
      –Toxic shock syndrome
      –Pancreatitis
    • Organic acidemia
    • Infant of a diabetic mother

    Workup and Diagnosis

    • History
      –Age at onset, age developmental milestones reached
      –Dietary intake, recurrent infections, medications
      –Paresthesias, jitteriness, seizures
      –Muscle cramping, tetany, carpal-pedal spasm
      –Cardiac disease, neck surgery
      –Autoimmune disorders, liver disease, renal disease
    • Physical exam
      –Vital signs, growth parameters
      –Facial dysmorphism (DiGeorge syndrome, PHP IA)
      –Skeletal deformities (bowed legs, widened wrists/ankles, rachitic rosary, frontal bossing)
      –Cardiac exam (heart murmur with DiGeorge)
      –DTRs for hyperreflexia, carpal-pedal spasm
      –Chvostek sign (twitching of circumoral muscles after tapping on facial nerve in front of the ear)
      –Trousseau sign (carpal-pedal spasm after maintaining arm BP cuff 20 mmHg above systolic BP for 3 minutes)
      –Thrush, vitiligo, alopecia, nail fungal infection (for Blizzard)
    • Labs: PTH, total and ionized calcium, vitamin D levels, alkaline phosphatase, LFT, BUN, Cr, magnesium, phosphorus, albumin; urine calcium and Cr
    • ECG: Prolonged QT interval
    • CXR: Absent thymus in DiGeorge
    • Long bone films: Rachitic changes
    • CT brain: Evaluate for calcification of basal ganglia

    » READ BOOK EXCERPT ONLINE »

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

    HYPOCALCEMIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Determining the serum phosphate and alkaline phosphatase levels will facilitate differentiating the causes of hypocalcemia. The phosphates and alkaline phosphatase are elevated in chronic nephritis but only the alkaline phosphatase is elevated in renal tubular acidosis and malabsorption syndrome. Only the phosphorus is elevated in hypoparathyroidism and pseudohypoparathyroidism. Hypoparathyroidism can be distinguished by a low serum PTH assay result.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Chvostek's sign: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Obtain a brief history. Find out if the patient has had his parathyroid glands surgically removed or if he has a history of hypoparathyroidism, hypomagnesemia, or a malabsorption disorder. Ask him or his family if they have noticed any changes in the patient's mental status, such as depression or slowed responses, which can accompany chronic hypocalcemia.

    » 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

    Hypoparathyroidism: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Confirming diagnosis  The following test results confirm the diagnosis of hypoparathyroidism:

    ❑ Radioimmunoassay for PTH: decreased PTH concentration

    ❑ Serum calcium: decreased

    ❑ Serum phosphorus: increased

    ❑ Electrocardiogram (ECG): prolonged QT and ST intervals due to hypocalcemia.

    Inflating a blood pressure cuff on the upper arm to between diastolic and systolic blood pressure and maintaining this inflation for 3 minutes elicits Trousseau’s sign (carpal spasm), thereby provoking clinical evidence of hypoparathyroidism.

    » READ BOOK EXCERPT ONLINE »

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

    Chvostek's sign: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Obtain a brief history. Find out if the patient has had the parathyroid glands surgically removed or if he has a history of hypoparathyroidism, hypomagnesemia, or malabsorption disorder. Ask him or his family if they have noticed any mental changes, such as depression or slowed responses, which can accompany chronic hypocalcemia.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth 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

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

    In simple goiter, patients are asymptomatic or, if the gland is sufficiently enlarged, they present with symptoms caused by mechanical pressure. Substernal goiters are frequently responsible for tracheal pressure symptoms, including dyspnea and inspiratory stridor. They can also obstruct the large cervical veins at the thoracic inlet, causing suffusion of the face, giddiness, and syncope (Pemberton’s sign). Esophageal compression can lead to dysphagia (Chapter 9.5). Hoarseness caused by compression of or traction on the recurrent laryngeal nerve is rare in simple goiter and suggests a malignancy (Chapter 6.3). Generalized thyroid pain suggests subacute thyroiditis, whereas sudden localized pain and swelling are consistent with hemorrhage into a nodule. Although simple goiters are usually euthyroid, typical symptoms of hypothyroidism or thyrotoxicosis should be sought. A family history of goiter and a personal history of residing in an endemic goiter area or ingesting goitrogens may be significant (1).

    Physical examination

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

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

    » READ BOOK EXCERPT ONLINE »

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

    Neck Mass/Thyroid Enlargement: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Neck Mass

    ❑ Inflammatory lymphadenopathy

    ❑ Parotid swelling/tumor

    ❑ Laryngeal cancer

    ❑ Intramuscular hematoma

    ❑ Lymphoma

    ❑ Nasopharyngeal carcinoma

    ❑ Branchial cleft cyst

    ❑ Thyroglossal duct cyst

    ❑ Supraclavicular adenopathy

    ❑ Aortic aneurysm

    ❑ Carotid aneurysm

    ❑ Ludwig angina

    ❑ Pharyngeal pouch

    ❑ Carotid body tumor

    Thyroid Enlargement

    ❑ Simple goiter

    ❑ Hashimoto thyroiditis

    ❑ Grave disease

    ❑ Drugs

    ❑ Subacute thyroiditis

    ❑ Thyroid cancer

    ❑ Infiltrative disease

    Diagnostic Approach

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Hypoparathyroidism: Diagnosis
    (Handbook of Diseases)

    The following test results confirm the diagnosis of hypoparathyroidism:

    ❑ radioimmunoassay for PTH — decreased PTH concentration

    ❑ serum calcium — decreased level

    ❑ serum phosphorus — increased level

    ❑ electrocardiography (ECG) — prolonged QT and ST intervals due to hypocalcemia.

    The following test helps provoke clinical evidence of hypoparathyroidism:

    ❑ Inflating a blood pressure cuff on the upper arm to between diastolic and systolic blood pressure and maintaining this inflation for 3 minutes elicits Trousseau’s sign (carpal spasm).

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Chvostek's sign: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Obtain a brief history. Find out if the patient has had the parathyroid glands surgically removed or if he has a history of hypoparathyroidism, hypomagnesemia, or malabsorption disorder. Ask him or his family if they have noticed any mental changes, such as depression or slowed responses, which can accompany chronic hypocalcemia. Question the patient about tingling around the mouth and in the fingertips and feet.

    » READ BOOK EXCERPT ONLINE »

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

    Chvostek's sign: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Obtain a brief history. Find out if the patient has had his parathyroid glands surgically removed or if he has a history of hypoparathyroidism, hypomagnesemia, or a malabsorption disorder. Ask him or his family if they have noticed changes in the patient's mental status, such as depression or slowed responses, which can accompany chronic hypocalcemia. Ask the patient if he has experienced any numbness and tingling in his fingers, toes, or around his mouth. Also ask him about muscle twitching or cramping.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    HYPOCALCEMIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Determining the serum phosphate and alkaline phosphatase levels will facilitate differentiating the causes of hypocalcemia. The phosphates and alkaline phosphatase are elevated in chronic nephritis, but only the alkaline phosphatase is elevated in renal tubular acidosis and malabsorption syndrome. Only the phosphorus is elevated in hypoparathyroidism and pseudohypoparathyroidism. Hypoparathyroidism can be distinguished by a low serum PTH assay result.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Signs of Hypoparathyroidism

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