Diseases » Obesity » Diagnosis

Diagnosis of Obesity

Diagnostic Test list for Obesity:

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

• Body Mass Index (BMI) - BMC 25..<30 is overweight; BMI >= 30 is obesity
• Weight-for-height charts
• Skinfold thickness measurement
• Bioelectrical impedance analysis (BIA)

Obesity Diagnosis: Book Excerpts

• Ask the Following Questions - OBESITY, PATHOLOGIC
• Ask the Following Questions - FEMORAL MASS OR SWELLING
• Ask the Following Questions - RECTAL MASS
• Differential Diagnosis - Rectal Masses
• Differential Diagnosis - Scrotal Masses
• Differential Diagnosis - Obesity
• Approach to the Diagnosis - OBESITY
• Approach to the Diagnosis - BACK MASS
• Approach to the Diagnosis - EPIGASTRIC MASS
• Approach to the Diagnosis - EXTREMITY MASS
• Approach to the Diagnosis - HYPOGASTRIC MASS
• Approach to the Diagnosis - RIGHT UPPER QUADRANT MASS
• Approach to the Diagnosis - LEFT LOWER QUADRANT MASS
• Approach to the Diagnosis - LEFT UPPER QUADRANT MASS
• Approach to the Diagnosis - NASAL MASS OR SWELLING
• Approach to the Diagnosis - RIGHT LOWER QUADRANT MASS
• Approach to the Diagnosis - CHEST WALL MASS
• Approach to the Diagnosis - RECTAL MASS
• History and physical examination - Abdominal distention
• Diagnosis - Obesity
• History and physical examination - Abdominal distention
• History - Mediastinal Mass
• History - Scrotal Mass
• Differential Overview - Obesity
• History - Abdominal distention
• Clinical Features and Diagnosis - Obesity
• History and physical examination - Abdominal distention
• Approach to the Diagnosis - BACK MASS
• Approach to the Diagnosis - EXTREMITY MASS
• Approach to the Diagnosis - FACE MASS
• Approach to the Diagnosis - OBESITY
• Approach to the Diagnosis - PULSATILE MASS
• Approach to the Diagnosis - Epigastric Mass
• Approach to the Diagnosis - Hypogastric Mass
• Approach to the Diagnosis - CHEST WALL MASS
• Approach to the Diagnosis - Right Upper Quadrant Mass
• Approach to the Diagnosis - NASAL MASS OR SWELLING
• Approach to the Diagnosis - Left Lower Quadrant Mass
• Approach to the Diagnosis - Left Upper Quadrant Mass
• Approach to the Diagnosis - RECTAL MASS
• Approach to the Diagnosis - Right Lower Quadrant Mass
• Mediastinal Mass - DIAGNOSIS - Mediastinal Mass

Tests and diagnosis discussion for Obesity:

Understanding Adult Obesity: NIDDK (Excerpt)

Everyone needs a certain amount of body fat for stored energy, heat insulation, shock absorption, and other functions. As a rule, women have more body fat than men. Most health care providers agree that men with more than 25 percent body fat and women with more than 30 percent body fat are obese.

Measuring the exact amount of a person's body fat is not easy. The most accurate measures are to weigh a person underwater or to use an X-ray test called Dual Energy X-ray Absorptiometry (DEXA). These methods are not practical for the average person, and are done only in research centers with special equipment.

There are simpler methods to estimate body fat. One is to measure the thickness of the layer of fat just under the skin in several parts of the body. Another involves sending a harmless amount of electricity through a person's body. Both methods are used at health clubs and commercial weight loss programs. Results from these methods, however, can be inaccurate if done by an inexperienced person or on someone with severe obesity.

Because measuring a person's body fat is difficult, health care providers often rely on other means to diagnose obesity. Weight-for-height tables, which have been used for decades, usually have a range of acceptable weights for a person of a given height. One problem with these tables is that there are many versions, all with different weight ranges. Another problem is that they do not distinguish between excess fat and muscle. A very muscular person may appear obese, according to the tables, when he or she is not.

In recent years, body mass index (BMI) has become the medical standard used to measure overweight and obesity. (Source: excerpt from Understanding Adult Obesity: NIDDK)

Understanding Adult Obesity: NIDDK (Excerpt)

Although the BMI ranges shown in the table are not exact ranges of healthy and unhealthy weight, they are useful guidelines. A BMI of 25 to 29.9 indicates a person is overweight. A person with a BMI of 30 or higher is considered obese. (Source: excerpt from Understanding Adult Obesity: NIDDK)

Am I at Risk for Type 2 Diabetes: NIDDK (Excerpt)

Body mass index (BMI) is a measure of body weight relative to height. You can use BMI to see whether you are underweight, normal weight, overweight, or obese. Use the body mass index table below to find your BMI.

• Find your height in the left-hand column.
• Move across in the same row to the number closest to your weight.
• The number at the top of that column is your BMI. Check the word above your BMI to see whether you are normal weight, overweight, or obese.

For a printer-friendly version of this table, use the pdf.*

	Normal						Overweight					Obese
BMI	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35	36
Height (inches)	Body Weight (pounds)
58	91	96	100	105	110	115	119	124	129	134	138	143	148	153	158	162	167	172
59	94	99	104	109	114	119	124	128	133	138	143	148	153	158	163	168	173	178
60	97	102	107	112	118	123	128	133	138	143	148	153	158	163	168	174	179	184
61	100	106	111	116	122	127	132	137	143	148	153	158	164	169	174	180	185	190
62	104	109	115	120	126	131	136	142	147	153	158	164	169	175	180	186	191	196
63	107	113	118	124	130	135	141	146	152	158	163	169	175	180	186	191	197	203
64	110	116	122	128	134	140	145	151	157	163	169	174	180	186	192	197	204	209
65	114	120	126	132	138	144	150	156	162	168	174	180	186	192	198	204	210	216
66	118	124	130	136	142	148	155	161	167	173	179	186	192	198	204	210	216	223
67	121	127	134	140	146	153	159	166	172	178	185	191	198	204	211	217	223	230
68	125	131	138	144	151	158	164	171	177	184	190	197	203	210	216	223	230	236
69	128	135	142	149	155	162	169	176	182	189	196	203	209	216	223	230	236	243
70	132	139	146	153	160	167	174	181	188	195	202	209	216	222	229	236	243	250
71	136	143	150	157	165	172	179	186	193	200	208	215	222	229	236	243	250	257
72	140	147	154	162	169	177	184	191	199	206	213	221	228	235	242	250	258	265
73	144	151	159	166	174	182	189	197	204	212	219	227	235	242	250	257	265	272
74	148	155	163	171	179	186	194	202	210	218	225	233	241	249	256	264	272	280
75	152	160	168	176	184	192	200	208	216	224	232	240	248	256	264	272	279	287
76	156	164	172	180	189	197	205	213	221	230	238	246	254	263	271	279	287	295

	Obese			Extreme Obesity
BMI	37	38	39	40	41	42	43	44	45	46	47	48	49	50	51	52	53	54
Height (inches)	Body Weight (pounds)
58	177	181	186	191	196	201	205	210	215	220	224	229	234	239	244	248	253	258
59	183	188	193	198	203	208	212	217	222	227	232	237	242	247	252	257	262	267
60	189	194	199	204	209	215	220	225	230	235	240	245	250	255	261	266	271	276
61	195	201	206	211	217	222	227	232	238	243	248	254	259	264	269	275	280	285
62	202	207	213	218	224	229	235	240	246	251	256	262	267	273	278	284	289	295
63	208	214	220	225	231	237	242	248	254	259	265	270	278	282	287	293	299	304
64	215	221	227	232	238	244	250	256	262	267	273	279	285	291	296	302	308	314
65	222	228	234	240	246	252	258	264	270	276	282	288	294	300	306	312	318	324
66	229	235	241	247	253	260	266	272	278	284	291	297	303	309	315	322	328	334
67	236	242	249	255	261	268	274	280	287	293	299	306	312	319	325	331	338	344
68	243	249	256	262	269	276	282	289	295	302	308	315	322	328	335	341	348	354
69	250	257	263	270	277	284	291	297	304	311	318	324	331	338	345	351	358	365
70	257	264	271	278	285	292	299	306	313	320	327	334	341	348	355	362	369	376
71	265	272	279	286	293	301	308	315	322	329	338	343	351	358	365	372	379	386
72	272	279	287	294	302	309	316	324	331	338	346	353	361	368	375	383	390	397
73	280	288	295	302	310	318	325	333	340	348	355	363	371	378	386	393	401	408
74	287	295	303	311	319	326	334	342	350	358	365	373	381	389	396	404	412	420
75	295	303	311	319	327	335	343	351	359	367	375	383	391	399	407	415	423	431
76	304	312	320	328	336	344	353	361	369	377	385	394	402	410	418	426	435	443

Source: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. (Source: excerpt from Am I at Risk for Type 2 Diabetes: NIDDK)

NIDDK _ Statistics Related to Overweight and Obesity: NIDDK (Excerpt)

A number of methods are used to determine if an individual is overweight or obese. Some of them are based on mathematical calculations of the relation between height and weight--others are based on measurements of body fat. These methods are described below.

Body Mass Index

Body Mass Index (BMI) can be used to measure both overweight and obesity in adults. It is the measurement of choice for many obesity researchers and other health professionals. BMI is a direct calculation based on height and weight, and it is not gender-specific. Most health organizations and published information on overweight and its associated risk factors use BMI to measure and define overweight and obesity. BMI does not directly measure percent of body fat, but it provides a more accurate measure of overweight and obesity than relying on weight alone.

BMI is found by dividing a person's weight in kilograms by height in meters squared. The mathematical formula is:

weight (kg)/height squared (m²).

To determine BMI using pounds and inches, multiply your weight in pounds by 704.5,* then divide the result by your height in inches, and divide that result by your height in inches a second time (Source: excerpt from NIDDK _ Statistics Related to Overweight and Obesity: NIDDK)

NIDDK _ Statistics Related to Overweight and Obesity: NIDDK (Excerpt)

The National Institutes of Health (NIH) identify overweight as a BMI of 25-29.9 kg/m², and obesity as a BMI of 30 kg/m² or greater. However, overweight and obesity are not mutually exclusive, since obese persons are also overweight.¹ Defining overweight as a BMI of 25 or greater is consistent with the recommendations of the World Health Organization ² and most other countries. (Source: excerpt from NIDDK _ Statistics Related to Overweight and Obesity: NIDDK)

NIDDK _ Statistics Related to Overweight and Obesity: NIDDK (Excerpt)

Weight-for-height charts are another measure used to determine if a person is overweight (although they do not measure body fat). These charts, which have been used by doctors and other health care workers for decades, usually give a range of acceptable weights for a person of a given height. Many versions of weight-for-height charts exist, some showing different acceptable weight ranges for men and women. Health care workers often disagree over which is the best chart to use. The 2000 Dietary Guidelines for Americans, published jointly by the U.S. Departments of Agriculture and Health and Human Services, provide the most up-to-date weight-for-height chart. The healthy weight range in this chart corresponds to a BMI between 18.5 and 25. (Source: excerpt from NIDDK _ Statistics Related to Overweight and Obesity: NIDDK)

NIDDK _ Statistics Related to Overweight and Obesity: NIDDK (Excerpt)

Measurements of Body Fat

There are a number of ways to measure body fat. Historically, the standard method is to weigh a person underwater; this procedure is limited to laboratories with specialized equipment.

Other simpler methods for measuring body fat include skinfold thickness measurements and bioelectrical impedance analysis (BIA). Skinfold thicknesses are measures of the subcutaneous (lying just beneath the skin) fat at specific sites of a person's body, such as the triceps (the back of the upper arm). Accurate measurements of skinfold thickness depend on the skill of the examiner and may vary widely when measured by different examiners.

To measure body fat using BIA, a harmless amount of an electrical current is sent through the body. The body's ability to conduct an electrical current reflects the total amount of water in the body. Generally, a higher percent body water indicates a larger amount of muscle and lean tissue. Mathematical equations are used to translate the percent body water measure into an indirect estimate of body fat and lean body mass. A standard method should be used to measure bioelectrical impedance because dehydration, recent exercise, skin and room temperature, and placement of electrodes all can affect test results. To obtain the most precise reading, the person being tested should fast for at least 4 hours and lie down for at least several minutes prior to testing. BIA may not be accurate in severely obese individuals, and it is not useful for tracking short-term changes in body fat brought about by diet or exercise.

In addition to body weight and height measurements, health professionals may also rely on a person's waist measurement to determine the location of excess body fat and the corresponding health risks. Analogous to BMI, health risks increase as waist circumference increases. A woman whose waist measures more than 35 inches and a man whose waist measures more than 40 inches may be at particular risk for developing health problems. Studies indicate that increased abdominal or upper body fat is related to the risk of developing heart disease, diabetes, high blood pressure, gallbladder disease, stroke, and certain cancers, and is associated with overall mortality (likelihood of death). Body fat concentrated in the lower body (around the hips, for example) may be less harmful in terms of mortality and morbidity (likelihood of disease), with the exception of varicose veins and orthopedic problems (Source: excerpt from NIDDK _ Statistics Related to Overweight and Obesity: NIDDK)

NIDDK _ Statistics Related to Overweight and Obesity: NIDDK (Excerpt)

The definitions or measurement characteristics for overweight and obesity have varied over time, from study to study, and from one part of the world to another. The varied definitions affect the prevalence statistics of studies and make it difficult to compare data from different studies and from different countries. (Source: excerpt from NIDDK _ Statistics Related to Overweight and Obesity: NIDDK)

Diet: NWHIC (Excerpt)

The words obesity and overweight are generally used interchangeably. However, according to the Institute of Medicine report, their technical meanings are not identical. Overweight refers to an excess of body weight that includes all tissues, such as fat, bone and muscle. Obesity refers specifically to an excess of body fat. It is possible to be overweight without being obese, as in the case of a body builder who has a substantial amount of muscle mass. It is possible to be obese without being overweight, as in the case of a very sedentary person who is within the desirable weight range but who nevertheless has an excess of body fat. However, most overweight people are also obese and vice versa. Men with more than 25 percent and women with more than 30 percent body fat are considered obese. The USFDA has released a chart detailing recommended weights relative to height; women should be in the lower end of their appropriate weight range, according to the chart. (Source: excerpt from Diet: NWHIC)

Diagnosis of Obesity: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Obesity:

• About metabolic syndrome
• Australia's cancer death rate is low but incidence of new cancers is relatively high
• Blood protein concentration may determine heart disease risk
• Bone problems for obese kids
• Cancer deaths take over deaths caused by heart disease
• Candida influenced by obesity and depression
• Children suffering adult disease
• Diabetes and risk reduction
• Different types of sleep disorders plague many millions of Americans
• GI diet to assist cystic ovary disease
• Implanted device alleviates previously untreatable seizure problems
• Metabolic syndrome and heart disease risk
• Native Americans at significant risk for heart problems
• Overweight men risk having their prostate cancer misdiagnosed
• Pancreatic cancer surgery less common in black men
• Pregnancy-induced hypertension predicts metabolic syndrome in later life.
• Sensorimotor neuropathy and autonomic neuropathy from diabetes
• Syndrome X in children
• Targeting high blood pressure in young men
• WHO concerned with increase incidence in stroke and heart disease
• More news »

Diagnostic Tests for Obesity: Online Medical Books

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

OBESITY, PATHOLOGIC: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there associated hyperphagia? If the patient recognizes that he or she has a ravenous appetite or eats more than is necessary, the possibility of an insulinoma or Fröhlich's syndrome should be considered.
2. Is the obesity centripetal? The presence of centripetal obesity, especially with moon facies, should suggest Cushing's syndrome.
3. Is the obesity mainly of the lower extremities? This finding would suggest lipodystrophy.
4. Is there mental retardation? The presence of mental retardation should suggest Laurence-Moon-Bardet-Biedl syndrome.
5. What is the sex of the patient? In male patients one should consider Klinefelter's syndrome, and in female patients one should consider polycystic ovary.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, urinalysis, chemistry panel, 2-hr postprandial blood sugar, and thyroid profile. If an insulinoma is strongly suspected, a 24- to 36-hr fast, a 5-hr glucose tolerance test, and tolbutamide tolerance test may be done. If Cushing's syndrome is suspected, a serum cortisol and cortisol suppression test should be done. Pelvic ultrasound will help diagnose polycystic ovaries. Chromosomal analysis will help diagnose Klinefelter's syndrome. Perhaps a psychiatrist should be consulted.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FEMORAL MASS OR SWELLING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it reducible? If the mass is reducible, it is most likely a femoral hernia or saphenous varix.
2. Is there an associated kyphotic curvature of the spine? The findings of a kyphotic curvature of the spine suggest a psoas abscess, which is usually tuberculous.
3. Is the mass firm and ovoid? A firm, ovoid mass suggests an enlarged lymph node or an ectopic testis.
4. Is there resonance or bowel sounds over the mass? These findings suggest a femoral hernia.
5. Is the corresponding half of the scrotum empty? These findings suggest an ectopic testis.

DIAGNOSTIC WORKUP

Surgical consultation may be wise at the outset. A reducible mass would suggest a femoral hernia, but an upper GI series with a small bowel follow-through would confirm this diagnosis. Of course, if it is felt that the femoral hernia is irreducible, this study would not be done, and exploratory surgery would be indicated. If the mass is suspected to be a lymph node, a biopsy should be done. If the mass is suspected to be an abscess, an incision and drainage should be done. If tuberculosis is suspected, a tuberculin test as well as an AFB smear and culture should be done. If the mass is suspected to be a saphenous varix, venography will confirm the diagnosis. Exploratory surgery of the groin will clarify the diagnosis in confusing cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

1. Is it painful? A painful rectal mass should suggest perirectal abscess, thrombosed hemorrhoid, anal ulcer, ruptured ectopic pregnancy, tubo-ovarian abscess, and pelvic appendix.
2. Is it soft or cystic? The presence of a soft or cystic mass would suggest internal hemorrhoids, polyps, intussusception, villous tumor, granular proctitis, ovarian cyst, and blood or pus in the cul-de-sac.
3. Is it hard? The presence of a hard lesion would suggest a fecal impaction, foreign body, retroverted uterus, enlarged prostate, malignant deposits in the pouch of Douglas, stricture, and carcinoma.
4. Is there associated bleeding? The presence of bleeding should make one suspect carcinoma above all else, but it may be due to internal hemorrhoids, polyps, intussusception, villous tumors, or granular proctitis.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, and urinalysis. A smear and culture should be made of any rectal or vaginal discharge. Most cases will be diagnosed by anoscopy and proctoscopy. A pelvic ultrasound and CT scan of the abdomen and pelvis may be useful in evaluating ectopic pregnancy and other gynecologic disorders. Ultrasound of the prostate may also be done to evaluate a prostatic mass. A gynecologist, proctologist, or urologist should be consulted in difficult cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Rectal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Hemorrhoids
• Rectal prolapse
• Rectal cancer
• Rectal polyp
• Prostate cancer
• Prostatitis
• Endometriosis
• Presacral neurogenic tumor
• Rectal intussusception
• Anal cancer (2% of colorectal cancers)
  –Anal canal tumors (above the anal verge) include adenocarcinoma, melanoma, and epidermoid tumors
  –Anal margin tumors (below the anal verge) include squamous cell carcinoma, verrucous (from condyloma acuminatum), basal cell carcinoma, Bowen's disease, and Paget's disease of the anus

• Foreign body
• Less common diagnoses (“zebras”) include rectal carcinoid, lymphoid hyperplasia, malignant lymphoma, lipoma, dermoid cyst, teratoma, rectal duplication, and leiomyosarcoma

Workup and Diagnosis

• History should include changes in bowel habits or consistency of stool, and family history of colorectal cancer
  –Bleeding is the most common symptom associated with benign and malignant lesions; melena suggests upper GI bleeding, blood on toilet paper suggests anal fissure or hemorrhoids, bright red separate from stool suggests hemorrhoids, clots in stool suggests colonic source
  –Pain is usually associated with benign pathology

• Fecal occult blood testing may be used for screening
• Digital rectal exam and anoscopy are used initially to distinguish many anorectal lesions
• Endoscopy (sigmoidoscopy and/or full colonoscopy) with biopsy of all polyps and suspicious lesions
• Barium enema is indicated if colonoscopy unavailable
• Endorectal ultrasound is necessary to evaluate for potential rectal cancer, to appropriately stage tumor invasion and lymph node status, and to direct appropriate treatment
• Manometry may be indicated in incontinent patients

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Source: In a Page: Signs and Symptoms, 2004

Scrotal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

Painful masses

• Torsion of the spermatic cord
  –Testicle rides higher on affected side
  –Neonate to early 20s
  –Sudden pain in one testicle, followed by swelling and erythema of scrotum

• Epididymitis
  –Testicle position is normal; tenderness at top and posterior of testicle
  –Childhood to old age
  –<35 years: Chlamydia, gonorrhea
  –>35 years: Enterobacteriaceae

Orchitis
–Testicle position normal
–Usually with epididymitis due to E. coli, Klebsiella, Pseudomonas; mumps

• Strangulated hernia (vascular compromise)
• Trauma
  Nonpainful masses
• Hernia
• Varicocele
  –A collection of dilated tortuous veins posterior to and above testis

• Testicular cancer
  –Most common at ages 15–35
  –Gradual onset, though may only be noticed incidentally following trauma

• Spermatocele
  –Firm, cystic mass containing sperm above and posterior to testis

• Hydrocele
  –Covers anterior surface of the testicle
  –Seen in infants but usually closes before 1 year of age, then reappears in men over 40

• Scrotal swelling
  –Edema from cardiac, hepatic, or renal failure

• Epididymal cyst
  –More common in males with in utero DES exposure

Sperm granuloma
–Usually at the site of a prior vasectomy

Less common etiologies include torsion of the appendices of the testis and epididymis, urinary extravasation, lipoma of spermatic cord, and pyogenic or granulomatous orchitis

Workup and Diagnosis

• History and physical examination including abdomen, back, genitalia, and digital rectal examination
  –Onset/duration of symptoms, evidence of trauma, past medical history (e.g., cryptorchidism, testicular atrophy or dysgenesis), family history (e.g. testicular cancer significantly increases risk), sexual activity, and history of GU instrumentation
  –Constitutional: Fever, weight loss, pain, face (e.g., parotid glands are enlarged in mumps), breast (e.g., gynecomastia), penis (e.g., ulcers, plaques, induration, urethral discharge), scrotum, and testicles
  –Compare size, position, and tenderness of testicles; transilluminate all masses; palpate spermatic cord and inguinal canals (explore for hernias, hidden testicles, cord tenderness); and digital rectal exam
  –Lift testicle up over symphysis pubis: Pain relieved in epididymitis (Prehn's sign); no change with torsion

• Initial laboratory testing may include CBC, urinalysis, urethral gram stain and culture
• Ultrasound is indicated in all patients; include Doppler flow study if torsion is suspected
  –Intratesticular masses are considered to be cancer until proven otherwise
• If solid mass is found, consider chest X-ray, CT of abdomen, serum tumor markers (AFP, β-hCG), LDH, electrolytes, BUN/creatinine, calcium, PT/PTT, and obtain urology consult and consider hematology-oncology consult

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Source: In a Page: Signs and Symptoms, 2004

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

• Exogenous obesity (most common)
  –No demonstrable disease as the cause
  –Excessive weight gain from imbalance between caloric intake and energy expenditure
  –Linear growth is robust and frequently accelerated

• Hormonal causes
  –Associated with poor linear growth
  –Hypercortisolism: Cushing syndrome is any type of glucocorticoid excess (endogenous or exogenous); Cushing disease describes pituitary ACTH overproduction
  –Hypothyroidism
  –Growth hormone deficiency

• Insulinoma
• Hypothalamic obesity
  –Tumors (e.g., craniopharyngiomas)
  –Following neurosurgery or irradiation
  –Head trauma
  –Infiltrative/inflammatory
• Genetic syndromes
  –Prader-Willi syndrome
  –Laurence-Moon-Bardet-Biedl syndrome
  –Alström syndrome
  –Cohen syndrome
  –Down syndrome
  –Carpenter syndrome
  –Grebe syndrome
  –Beckwith-Wiedemann syndrome
• Defects in metabolic/eating regulatory pathways is an area of intense investigation; multiple mutations are theoretically possible, but only a few have actually been discovered in humans
  –Congenital leptin deficiency (extremely rare)
  –Leptin resistance (more common than deficiency)
• Drugs
  –Chronic glucocorticoids
  –Neuropsychotropic medications
• Adiposogenital dystrophy syndrome

Workup and Diagnosis

• History: Age and course of onset; linear growth progression; birth and neonatal history (tone, failure to thrive); polydipsia, polyuria, polyphagia; dietary intake, physical activity; cold intolerance, constipation, dry skin, headaches; abdominal pain, onset of puberty if pubertal; developmental delay (genetic syndromes); family history of obesity and genetic disorders
• Physical exam: Vital signs (blood pressure); growth parameters (height, weight, BMI); distribution of fat, moon or coarse facies, pallor, buffalo hump, striae (Cushingoid appearance); acanthosis nigricans (dark velvety areas in skin folds; cutaneous marker of insulin resistance); abdominal masses, micropenis, hypogonadism; depressed deep tendon reflexes; in infants skin “puddling,” midline defects
• Diagnostic workup
  –24-hour urine free cortisol/creatinine ratio (best screen for Cushing syndrome)
  –MRI (hypothalamic/pituitary mass)
  –Adrenal ultrasound (if suspect adrenal mass)
  –Thyroid function tests (T4, TSH)
  –IGF-I and IGFBP-3; possibly provocative growth hormone testing (if suspect GH deficiency)
  –Genetic (FISH) testing for genetic syndromes
  –Serum leptin
• Labs: Urinalysis for glucose, serum glucose, fasting serum insulin, hemoglobin A1c
  –Fasting lipid profile, urine microalbumin

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

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

It would be ridiculous to do a complete endocrine workup on every case of obesity, but thyroid function studies may be worthwhile. Patients who fail to lose weight on a strict diet may require hospitalization with observation. If they still fail to lose weight, a complete endocrine workup would seem to be indicated.

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Source: Differential Diagnosis in Primary Care, 2007

BACK MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

With skin lesions, excision or biopsy is frequently the best approach. Masses of the deeper structures cannot be approached as aggressively until certain conditions have been ruled out by computed tomography (CT) scans and bone scans. If a meningocele or similar congenital lesion is suspected, a neurosurgeon must be consulted.

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Source: Differential Diagnosis in Primary Care, 2007

EPIGASTRIC MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs are very helpful in determining the origin of an epigastric mass. If there is jaundice, the mass is probably an enlarged liver. Fever and chills suggests a subphrenic abscess displacing the liver downward or an abscessed gallbladder. A mass associated with a history of anorexia and wasting suggests pancreatic or gastric carcinoma. A history of alcoholism suggests that the mass is an enlarged liver or pancreatic pseudocyst. Blood in the stool suggests carcinoma of the stomach or colon. A history of constipation would warrant a cleansing enema to rule out a fecal impaction before ordering an expensive workup. If the mass pulsates, one would consider an aortic aneurysm in the differential diagnosis.

The initial workup should include a CBC, urinalysis, chemistry panel, amylase and lipase levels, stool for occult blood, and flat and upright x-rays of the abdomen. If a presentation is acute, a general surgeon should be consulted to consider immediate exploratory laparotomy. If the development was more insidious and the patient is in no acute distress, a more systematic workup can be done at this point. Based on the results of the initial workup, one can proceed with an upper GI series, a barium enema, or ultrasonography of the gallbladder and pancreas. However, a more expeditious route to the diagnosis would be to order a CT scan of the abdomen. It is wise to consult a surgeon or gastroenterologist to help decide what method would be the most cost-effective and prudent.

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Source: Differential Diagnosis in Primary Care, 2007

EXTREMITY MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the lesion is suspected to arise in the skin, simple biopsy or excision is the best approach. Deeper masses require careful examination, x-rays of the bones and soft tissue, bone scans, CT scans, ultrasonographic studies, and phlebography, arteriography, or lymphangiography. Surgical exploration of the area may be the only means to accomplish a specific diagnosis.

Approach to the Diagnosis

Because the extremities are not considered vital areas, the primary method of diagnosing the cause of a mass is exploration and biopsy. This is all well and good when the lesion is on the skin or subcutaneous tissue; however, when the mass is in the deeper tissues, it is wise to utilize diagnostic test to determine what the mass is before exploration. If the mass is suspected to be a varix or aneurysm, ultrasonography can be extremely useful in defining it. If the mass is attached to or thought to originate in bone, x-rays of the area and bone scans are useful. If it is uncertain what tissue the mass originates from, a CT scan can be used to help define it. Before ordering any of the above tests, it is best to consult a general or orthopedic surgeon to help select the most appropriate test for the case at hand.

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Source: Differential Diagnosis in Primary Care, 2007

HYPOGASTRIC MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Before the clinician can evaluate a hypogastric mass, it is important to have the patient empty his or her bladder. If the mass is still present, catheterization for residual urine or ultrasonography can determine if the mass is a distended bladder due to a neurogenic bladder or bladder neck obstruction. If there are objective neurologic findings, there may be a neurogenic bladder and the patient should be referred to a neurologist. If the clinician suspects bladder neck obstruction, a referral to a urologist is in order.

Once the possibility that the mass is a distended bladder has been excluded, one should consider ruling out pregnancy in women of childbearing age. A pregnancy test is done and if this is positive, ultrasonography may be done particularly if an ectopic pregnancy is suspected or the patient denies that she could be pregnant.

Once a distended bladder and pregnancy have been removed from consideration, the next step would be a CT scan of the abdomen and pelvis. It is probably wise to consult a gynecologist, general surgeon, or urologist before ordering this expensive test. Their wisdom may make the test unnecessary.

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Source: Differential Diagnosis in Primary Care, 2007

RIGHT UPPER QUADRANT MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Acute onset of the RUQ mass with a history of trauma is no doubt a laceration or contusion of the liver or kidney: A surgeon should be consulted immediately. When an RUQ mass is discovered unexpectedly or on a routine physical examination, one may proceed more deliberately. Ultrasonography will help determine if the mass is a gallbladder, a liver, or pancreatic cyst. A CBC, chemistry profile, and liver panel will help determine if the mass is hepatic in origin. An intravenous pyelogram (IVP), urinalysis, or urine culture will help determine if it is renal in origin. However, a CT scan can resolve the dilemma quickly in most cases so it may be the most cost-effective approach. Then, one can determine which specialist to refer the patient to without hesitation. It is important to remember that whereas most masses will require referral to a specialist, fecal impactions and abdominal wall hematomas can be handled by the primary care physician.

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Source: Differential Diagnosis in Primary Care, 2007

LEFT LOWER QUADRANT MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to this diagnosis includes a careful pelvic and rectal examination, a search for the presence of blood in the stool, a history of weight loss, tenderness of the mass, fever and other symptoms, and a laboratory workup. As mentioned above, an enema may diagnose and treat a fecal impaction. A surgical consult is wise at this point. Stool examination (for blood, ova, and parasites), sigmoidoscopy, and barium enemas are the most useful diagnostic procedures other than a colonoscopy. Arteriography and gallium scans (for diverticular and other abscesses) and the CT scan have become useful additions to the diagnostic armamentarium. Peritoneoscopy and exploratory laparotomy are still necessary in many cases.

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Source: Differential Diagnosis in Primary Care, 2007

LEFT UPPER QUADRANT MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The presence or absence of other symptoms and signs is the key to the clinical diagnosis of an LUQ mass. The presence of jaundice would suggest the mass is a large spleen. The presence of blood in the stool would suggest carcinoma of the colon. The presence of hematuria would suggest the mass is renal in origin. An enema should be done to exclude fecal impaction before an extensive workup is performed.

A conservative workup will include a CBC, sedimentation rate, urinalysis, chemistry panel, platelet count, stool for occult blood, coagulation profile, and a flat plate of the abdomen. On the basis of these results, the clinician can determine whether to do an upper gastrointestinal (GI) series, barium enema, IVP, or CT scan of the abdomen. Another approach would be to do the CT scan immediately. In the long run, the latter approach may be more cost-effective. It is usually prudent to get a surgical or gastroenterology consult to help decide between the two approaches.

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Source: Differential Diagnosis in Primary Care, 2007

NASAL MASS OR SWELLING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis is not difficult except in the case of granulomas and carcinomas, when skillful biopsy and culture are necessary. In Wegener midline granuloma, a search for alveolitis and glomerulonephritis will help determine the diagnosis. Serum for ANCA antibodies is often diagnostic.

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Source: Differential Diagnosis in Primary Care, 2007

RIGHT LOWER QUADRANT MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

As with other abdominal masses, its important to look for other symptoms and signs that will help determine the origin of the mass. If there are fever and chills, an appendiceal or diverticular abscess is possible. Blood in the stools suggests a diagnosis of colon carcinoma. If there is amenorrhea or vaginal bleeding in a woman of childbearing age, an ectopic pregnancy most be considered. A long history of chronic diarrhea with or without blood in the stools suggests Crohn disease.

The initial workup will include a CBC, sedimentation rate, chemistry panel, stool for occult blood, pregnancy test, and flat plate of the abdomen. If there is fever and an acute presentation, consultation with a general surgeon to consider an immediate exploratory laparotomy is indicated.

With a more insidious onset of the RLQ mass, the clinician has a choice of ordering a CT scan of the abdomen and pelvis after performing the initial diagnostic studies or proceeding systematically with a barium enema, IVP, or small-bowel series to determine the origin of the mass. A gastroenterology or gynecology consult may be the best way to resolve this dilemma.

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Source: Differential Diagnosis in Primary Care, 2007

CHEST WALL MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to this diagnosis is again a good clinical history and physical examination along with correlation of signs and symptoms. Chest x-ray films with special views and tomography will diagnose most cases, but a biopsy, arteriography, CT scans, and exploratory surgery may be necessary, especially if the lesion turns out to be noninfectious. It is important not to be fooled by a congenital anomaly (e.g., pigeon breast).

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Source: Differential Diagnosis in Primary Care, 2007

RECTAL MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Anoscopy, sigmoidoscopy, and a barium enema are the most significant tools in the proctologist’s armamentarium. Biopsy or excision of polyps is routine. When one polyp is found, a barium enema or colonoscopy is always done to look for others.

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Source: Differential Diagnosis in Primary Care, 2007

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

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat. (See Abdominal distention: Common causes and associated findings.)

The patient may also feel unable to bend at his waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites, page 4.) Also, note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, such as falling off a stepladder.

Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obesity. Inspect the abdomen for signs of inguinal or femoral hernia and for incisions that may point to adhesions. Both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash — a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. However, an abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally with the patient in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen without shifting dullness, prominent tympany, or palpable bowel or other masses, with generalized rather then localized dullness.

Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient’s abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.

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

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

Observation and comparison of height and weight to a standard table indicate obesity. Measurement of the thickness of subcutaneous fat folds with calipers provides an approximation of total body fat. Although this measurement is reliable and isn’t subject to daily fluctuations, it has little meaning for the patient in monitoring subsequent weight loss. Obesity may lead to serious complications, such as respiratory difficulties, hypertension, cardiovascular disease, diabetes mellitus, renal disease, gallbladder disease, psychosocial difficulties, and premature death.

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

Abdominal distention: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heartbeat, and difficulty breathing deeply or breathing when lying flat. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.

Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, glistening skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or an umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obese individuals. Inspect the abdomen for signs of an inguinal or femoral hernia and for incisions that may point to adhesions; both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for a succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally when the patient is in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen with generalized rather then localized dullness and without shifting dullness, prominent tympany, or palpable bowel or other masses.

Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference point for subsequent measurements. (See Abdominal distention: Causes and associated findings, pages 6 and 7.)

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

Mediastinal Mass: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Most mediastinal masses, including lymphomas, do not cause symptoms; however, it is important to pay early attention even to vague symptoms because most symptomatic patients with a mediastinal tumor will have a malignancy. Patients may be completely asymptomatic or their complaints can relate to the underlying disease process: myasthenia gravis or anemia from red cell aplasia, with thymoma; flushing, diarrhea, or Cushing’s syndrome, with thymic carcinoid; fatigue and irritability with parathyroid adenoma; fever, night sweats, and pruritus with lymphoma or Hodgkin’s; cough, wheezing, dysphagia, or chest pain, with compression or invasion of mediastinal organs (5). A personal or family history of cancer or aneurysms might be significant. Be especially alert to patients with prior tumors, even if benign. Some lesions can recur after many years (thymoma).

 B. Possible symptoms include fatigue, general weakness, cough, pruritus, chest pain, fever, night sweats, wheezing, dysphagia, stridor, voice change, hoarseness, weight loss, paresthesias, pain, proximal muscle weakness, swelling of face, and venous distention of neck (superior vena cava syndrome).

Physical examination

A. A general examination before an x-ray study gives clue to a mediastinal mass: vital signs, especially temperature, heart rate, and weight; check for pallor, skin lesions, lymphadenopathy, thyromegaly, splenomegaly, other abdominal or pelvic organomegaly or masses, rashes, weakness; auscultate lungs for wheezes, rales, and rhonchi.

 B. Focused reexamination after a mass is detected. Vital signs, especially temperature, heart rate, and documentation of weight loss; check carefully for cervical adenopathy (suitable for biopsy), evidence of thyromegaly, voice quality, airway patency sitting and supine; and observe the swallowing function. Auscultate the lungs for wheezes, rales, rhonchi; the heart for pericardial rubs; recheck for adenopathy (total body), check skin for melanoma, check testes for masses, and repeat the pelvic examination for ovarian masses.

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

Scrotal Mass: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Pain. Is the mass painful? How painful? Testicular torsion usually presents with severe pain. Torsion of a testicular or epididymal appendage, strangulated hernias, orchitis, or epididymitis can also be very painful. Varicocele, hydrocele, spermatocele, and testicular tumors are typically painless, but may at times present with a dull ache or heaviness of the scrotum.

B. Inciting event. Did the mass first appear after vigorous activity or testicular trauma? Torsion is often precipitated by one of these factors, whereas a new swelling following minor trauma can suggest bleeding associated with a tumor.

 C. Patient age. Based on a review of 238 testicular masses in children, torsion of an appendage is the most common cause of acute masses in children aged up to 13 years. Above this age epididymitis and testicular torsion become more common (2). The incidence of testicular torsion peaks in the age group 13 to 15 years (2), but it can also occur in both middle-aged males and neonates. Indeed, torsion accounts for 83% of acute scrotal masses in children aged less than 1 year (2). The average age for patients with testicular cancer is 32 years (1). Hydrocele, epididymitis, varicocele, and hernias are more common in adults; as with most scrotal masses, however, they occur over a wide range of ages.

 D. Duration. How long has the mass been present? Torsion typically presents with sudden onset of symptoms, leading patients to seek care soon after appearance of the mass. Other acute conditions can also have an abrupt onset. Many benign scrotal masses have been noted for some time by the patient. Abrupt appearance of a varicocele in an older man can signal venous obstruction. In such cases, consider renal tumor with spermatic vein occlusion if the varicocele is on the left and vena cava obstruction if it is on the right.

 E. Symptoms of infection. Is there a history of fever, penile discharge, mumps, or any other infection recently? Epididymitis often presents with discharge and mild fever. A high fever often accompanies orchitis. Mumps orchitis typically occurs 3 to 4 days after the parotitis. Many other infections, including tuberculosis and syphilis, can produce epididymitis or orchitis.

F. Previous history. Have the symptoms previously appeared? Patients with torsion may have had similar, milder symptoms in the past (torsion that spontaneously resolved). Patients with chronic epididymitis generally describe an initial severe bout that has been followed by milder recurrences.

 G. Other associated symptoms. Are there any other symptoms? Nausea often accompanies torsion and orchitis.

Physical examination

A. Palpation of scrotum and contents:

 1. Determine the orientation of the testicle. A torsed testicle is usually retracted upward and rotated to an abnormal position. This may be indicated by an epididymis that appears to lie in an abnormal location (normally, the head of the epididymis lies at the superior pole of the testicle and its body extends posterolateral along the testicle). Comparison with the other testicle may help with this determination. Normal position does not rule out torsion, however, as the testicle may have rotated a full 360°, or swelling can make accurate assessment of the position difficult.

 2. Assess for swelling and tenderness. Torsion, orchitis, and epididymitis all develop swelling and tenderness soon after onset. The swelling often obscures normal anatomy.

 3. Determine location of mass. Appendices of the epididymis and testicle can extend from the superior pole of either structure. Spermatocele is most commonly found superior and posterior to the testicle. Varicocele occurs in a similar location, most commonly on the left side. In epididymitis, the epididymis is usually diffusely swollen, which makes it difficult to distinguish epididymis from testicle.

 4. Assess the consistency of the mass. A varicocele typically has the consistency of a bag of worms. Hydrocele and spermatocele usually have a cystic consistency. Hydrocele can become tenser as the day progresses (because of the dependent position).

 B. Assess the cremasteric reflex. When the inner thigh is lightly stroked, the testicle on that side should rise noticeably. Absence of this reflex suggests torsion of the testicle (3).

 C. Elevate the testicle. This usually relieves the pain of epididymitis but not of torsion (3).

 D. Transilluminate the mass. Hydrocele and spermatocele will transilluminate.

 E. Examine the patient in both the supine and standing positions. Hernias and varicocele usually become more prominent on standing. Have the patient perform the Valsalva maneuver while standing, which may further accentuate these findings.

 F. General examination. Tumors can be associated with metastases or gynecomastia (Chapter 14.2).

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

Obesity: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Caloric excess

❑ Depression

❑ Drugs

❑ Hypothyroidism

❑ Hypogonadism

❑ Cushing syndrome

❑ Polycystic ovary syndrome

❑ Hypothalamic

❑ Insulinoma

Diagnostic Approach

Body mass index (BMI) 5 mass (kilograms)/height (meters)². Overweight is
a BMI 25 to 30 kg/m² and obesity is a BMI .30 kg/m². A body mass index .30 correlates with increased risk of type 2 diabetes, sleep apnea syndrome, fatty liver, gallstones, gout, degenerative joint disease, and accelerated atherogenesis. Abdominal obesity (waist–hip ratio .0.95 in men and .0.85 in women) with excess visceral (intra-abdominal) fat is associated with elevated trigylceride, insulin and glucose levels, and confers an especially increased incidence of adverse outcomes.

Less than 1% of patients with obesity have an endocrine or other secon-dary cause.

Rapid weight gain is usually due to fluid accumulation, seen with congestive heart failure, renal failure or chronic liver disease. Ascites with the latter can
produce a prominent abdomen, which can be mistaken for obesity by the patient.

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Source: Field Guide to Bedside Diagnosis, 2007

Abdominal distention: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing when lying flat or breathing deeply. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, and inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.

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

Obesity: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Genetic Influences and Environmental Factors

In >99% ofobese children, the cause is a complex interaction between geneticinfluences and environmental factors leading to caloric intake inexcess of caloric expenditure. In general these children have normalphysical exam with normal intelligence, normal genital development,and normal or above average height for age. No further diagnosticinvestigation is necessary.

Whitaker et al. (1997) showed thatobesity in 1 or both parents can help predict a child'srisk of obesity in adulthood. In the past few years, 5 single-genedisorders resulting in early-onset obesity have been reported (Farooqiand O'Rahilly, 2000).

Endocrine Disorders

Endocrine causes of obesity are unusual exceptfor chronic corticosteroid therapy. Attenuation of growth velocityis characteristic of glucocorticoid excess, hypothyroidism, andgrowth hormone deficiency.

Glucocorticoid Excess

The term "Cushingsyndrome" is used to describe any type of glucocorticoidexcess. Most common cause of glucocorticoid excess in childhoodis chronic corticosteroid therapy. Other causes include adrenalhyperplasia and adrenal tumors (adenoma, carcinoma).

Cushing disease refers to pituitaryoverproduction of ACTH, which occurs with pituitary adenoma. EctopicACTH syndrome is production of excessive amount of ACTH from nonadrenalsource (neuroblastoma, Wilms tumor, thymoma, carcinoid).

Clinical features of glucocorticoidexcess include round facies, buffalo hump, hypertension, increasedweight gain, and decreased linear growth. Normally, serum cortisolconcentration tends to be higher in morning and lower in evening.Loss of this normal diurnal variation is screening test for Cushing syndrome.

Low-dose dexamethasone suppressiontest helps distinguish whether glucocorticoid excess is due to adrenalor pituitary cause. In low-dose test in normal individuals, plasmacortisol is decreased to <5 μg/dL. Individualswith Cushing disease usually fail to suppress cortisol with low-dosetest, but suppress with high-dose test. MRI should be performedwith suspected pituitary disease, although some tumors secretingACTH may be invisible with current techniques.

Failure to suppress cortisol secretionwith high-dose dexamethasone test usually indicates adrenal tumoror ectopic ACTH syndrome. Serum cortisol is high and ACTH is lowwith adrenal hyperplasia and adrenal tumors. ACTH stimulation testwith measurement of serum cortisol may help distinguish adrenaladenoma from adrenal carcinoma. Serum cortisol concentration usuallyincreases with adrenal adenoma, whereas no response occurs withadrenal carcinoma. With suspected adrenal tumor, CT of abdomen shouldbe performed. Both serum cortisol and ACTH concentrations are veryhigh with ectopic ACTH syndrome. Further investigation includingimaging is necessary to determine location and extent of tumor.

Hypothyroidism

Characteristic features of hypothyroidism,which may be congenital or acquired, are slow linear growth, dryhair and skin, constipation, cold intolerance, and sometimes enlargedthyroid gland. Thyroid hormone serum level [thyroxine (T₄)or free T₄] is low, whereas TSHlevel is high.

Growth Hormone Deficiency

Most striking feature of growth hormone deficiencyis severe decrease in postnatal linear growth (see Chap. 23, Growth Deficiency: Weight and Height).

Hypothalamic Dysfunction

Hypothalamiclesions associated with increased weight gain include neoplasm,trauma, and inflammatory disorders, but mechanism remains elusive.

Continuous food intake results in massiveweight gain.

CT and MRI help locate and define extentof lesion.

Polycystic Ovary Syndrome

Usuallyoccurs at puberty and is characterized by obesity, hirsutism, secondaryamenorrhea, and bilateral enlarged polycystic ovaries.

Ovaries may be palpable on exam andcan be demonstrated by pelvic U/S.

Hyperinsulinemia with insulin resistanceand acanthosis nigricans also may occur, especially in overweightindividuals. Measurement of fasting blood glucose and insulin levelsscreen for insulin resistance.

Cause of this disorder remains to bedetermined.

Syndromes

Alstrom Syndrome

This autosomal-recessive disorder, whosegene locus has been mapped to chromosome 2p13, is characterizedby obesity, usually occurring at 2–10 yrs, retinitis pigmentosawith visual loss, sensorineural hearing loss, acanthosis nigricans,chronic renal disease, diabetes mellitus with insulin resistance,and normal intelligence.

Bardet-Biedl Syndrome

Characterized by obesity, polydactyly, hypogonadism,pigmentary retinopathy with progressive decrease in visual acuity,and mental retardation. It has been linked to several genetic loci.

Carpenter Syndrome

Besides increased weight gain, characteristicfindings include flat nasal bridge, low-set ears, high-arched palate,lateral displacement of inner canthi, brachycephaly with craniosynostosis,polydactyly and partial syndactyly of feet, brachydactyly and partialsyndactyly of hands, and mental retardation.

Cohen Syndrome

In thisautosomal-recessive disorder, whose gene locus has been mapped tochromosome 8q22-q23, onset of obesity is in middle of childhood.

Clinical features include typical facieswith high nasal bridge, malar hypoplasia, short philtrum, prominentmaxillary central incisors and lips, and mild down-slanting palpebralfissures; narrow hands and feet with elongated fingers and toes;retinal degeneration with decreased vision; hypotonia; seizures;and mild mental retardation.

Prader-Willi Syndrome

Althoughthis disorder can occur in families, most instances are sporadic.

Clinical criteria for diagnosis havebeen described by Holm et al. (1993). These individuals have narrowface, almond-shaped eyes, small mouth with thin lips; developmentaldelay; mild to moderate mental retardation; and hyperphagia withobsessive food-seeking behavior. Obesity develops before 6 yrs ofage.

Deletions on proximal long arm of chromosome15 account for 70–80% of cases. The remainderare due to chromosome translocations and maternal uniparental disomy15. Fluorescence in situ hybridization (FISH) can detect the deletions.

Diagnostic Approach

If physicalexam and linear growth are normal, combination of genetic influencesand environmental factors is almost always the cause of obesity.

If decreased linear growth occurs,glucocorticoid excess, hypothyroidism, and growth hormone deficiencyshould be considered.

Many unusual syndromes associated withobesity may be distinguished by their clinical findings and moleculargenetic analysis.

>

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

Abdominal distention: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's abdominal distention isn't acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat.

The patient may be unable to bend at the waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) When did the patient last have a bowel movement? Note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones such as falling off a stepladder.

Perform a complete physical examination. Don't restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it's also common in obesity and pregnancy. Inspect the abdomen for signs of inguinal or femoral hernia and for healed incisions that may point to adhesions. Both may lead to intestinal obstruction. Auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally with the patient in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen without shifting dullness, prominent tympany, or palpable bowel or other masses, with generalized rather then localized dullness.

Palpate the abdomen for tenderness, noting whether it's localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney's point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient's abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

BACK MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

With skin lesions, excision or biopsy is frequently the best approach. Masses of the deeper structures cannot be approached as aggressively until certain conditions have been ruled out by computed tomography (CT) scans and bone scans. If a meningocele or similar congenital lesion is suspected, a neurosurgeon must be consulted.

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Source: Differential Diagnosis in Primary Care, 2007

EXTREMITY MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the lesion is suspected to arise in the skin, simple biopsy or excision is the best approach. Deeper masses require careful examination, x-rays of the bones and soft tissue, bone scans, CT scans, ultrasonographic studies, and phlebography, arteriography, or lymphangiography. Surgical exploration of the area may be the only means to accomplish a specific diagnosis.

Approach to the Diagnosis

Because the extremities are not considered vital areas, the primary method of diagnosing the cause of a mass is exploration and biopsy. This is all well and good when the lesion is on the skin or subcutaneous tissue; however, when the mass is in the deeper tissues, it is wise to utilize diagnostic tests to determine what the mass is before exploration. If the mass is suspected to be a varix or aneurysm, ultrasonography can be extremely useful in defining it. If the mass is attached to or thought to originate in bone, x-rays of the area and bone scans are useful. If it is uncertain what tissue the mass originates from, a CT scan can be used to help define it. Before ordering any of the above tests, it is best to consult a general or orthopedic surgeon to help select the most appropriate test for the case at hand.

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Source: Differential Diagnosis in Primary Care, 2007

FACE MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If infection is suspected, smears and cultures of exudates should be done. X-rays of the skull, sinuses, and jaw may be helpful. A computed tomography (CT) scan will be more definitive. If neoplasm or granuloma is suspected, a biopsy or excision will be necessary. If there is still doubt about the etiology, an oral surgeon or otolaryngologist should be consulted.

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Source: Differential Diagnosis in Primary Care, 2007

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

It would be ridiculous to do a complete endocrine workup on every case of obesity, but thyroid function studies may be worthwhile. Patients who fail to lose weight on a strict diet may require hospitalization with observation. If they still fail to lose weight, a complete endocrine workup would seem to be indicated.

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Source: Differential Diagnosis in Primary Care, 2007

PULSATILE MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Ultrasonography will usually confirm the diagnosis of these lesions, but a CT scan or angiography may be necessary, particularly when surgical intervention is planned. A cardiovascular surgeon should be consulted before ordering these expensive tests.

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Source: Differential Diagnosis in Primary Care, 2007

Epigastric Mass: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs are very helpful in determining the origin of an epigastric mass. If there is jaundice, the mass is probably an enlarged liver. Fever and chills suggests a subphrenic abscess displacing the liver downward or an abscessed gallbladder. A mass associated with a history of anorexia and wasting suggests pancreatic or gastric carcinoma. A history of alcoholism suggests that the mass is an enlarged liver or pancreatic pseudocyst. Blood in the stool suggests carcinoma of the stomach or colon. A history of constipation would warrant a cleansing enema to rule out a fecal impaction before ordering an expensive workup. If the mass pulsates, one would consider an aortic aneurysm in the differential diagnosis.

The initial workup should include a CBC, urinalysis, chemistry panel, amylase and lipase levels, stool for occult blood, and flat and upright x-rays of the abdomen. If a presentation is acute, a general surgeon should be consulted to consider immediate exploratory laparotomy. If the development was more insidious and the patient is in no acute distress, a more systematic workup can be done at this point. Based on the results of the initial workup, one can proceed with an upper GI series, a barium enema, or ultrasonography of the gallbladder and pancreas. However, a more expeditious route to the diagnosis would be to order a CT scan of the abdomen. It is wise to consult a surgeon or gastroenterologist to help decide what method would be the most cost-effective and prudent.

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Source: Differential Diagnosis in Primary Care, 2007

Hypogastric Mass: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Before the clinician can evaluate a hypogastric mass, it is important to have the patient empty his or her bladder. If the mass is still present, catheterization for residual urine or ultrasonography can determine if the mass is a distended bladder due to a neurogenic bladder or bladder neck obstruction. If there are objective neurologic findings, there may be a neurogenic bladder and the patient should be referred to a neurologist. If the clinician suspects bladder neck obstruction, a referral to a urologist is in order. After the possibility that the mass is a distended bladder has been excluded, one should consider ruling out pregnancy in women of childbearing age. A pregnancy test is done: If the test is positive, ultrasonography may be done particularly if an ectopic pregnancy is suspected or the patient denies that she could be pregnant. After a distended bladder and pregnancy have been removed from consideration, the next step would be a CT scan of the abdomen and pelvis. It is probably wise to consult a gynecologist, general surgeon, or urologist before ordering this expensive test. Their wisdom may make the test unnecessary.

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Source: Differential Diagnosis in Primary Care, 2007

CHEST WALL MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to this diagnosis is again a good clinical history and physical examination along with correlation of signs and symptoms. Chest x-ray films with special views and tomography will diagnose most cases, but a biopsy, arteriography, CT scans, and exploratory surgery may be necessary, especially if the lesion turns out to be noninfectious. It is important not to be fooled by a congenital anomaly (e.g., pigeon breast).

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Source: Differential Diagnosis in Primary Care, 2007

Right Upper Quadrant Mass: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Acute onset of the RUQ mass with a history of trauma is no doubt a laceration or contusion of the liver or kidney: A surgeon should be consulted immediately. When an RUQ mass is discovered unexpectedly or during a routine physical examination, one may proceed more deliberately. Ultrasonography will help determine if the mass is a gallbladder, liver, or pancreatic cyst. A CBC, chemistry profile, and liver panel will help determine if the mass is hepatic in origin. An intravenous pyelogram (IVP), urinalysis, or urine culture will help determine if it is renal in origin. However, a CT scan can resolve the dilemma quickly in most cases so it may be the most cost-effective approach. Then, one can determine which specialist to refer the patient to without hesitation. It is important to remember that whereas most masses will require referral to a specialist, fecal impactions and abdominal wall hematomas can be handled by the primary care physician.

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Source: Differential Diagnosis in Primary Care, 2007

NASAL MASS OR SWELLING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis is not difficult except in the case of granulomas and carcinomas, when skillful biopsy and culture are necessary. In Wegener midline granuloma, a search for alveolitis and glomerulonephritis will help to determine the diagnosis. Serum for ANCA antibodies is often diagnostic.

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Source: Differential Diagnosis in Primary Care, 2007

Left Lower Quadrant Mass: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to this diagnosis includes a careful pelvic and rectal examination, a search for the presence of blood in the stool, a history of weight loss, tenderness of the mass, fever and other symptoms, and a laboratory workup. As mentioned above, an enema may diagnose and treat a fecal impaction. A surgical consult is wise at this point. Stool examination (for blood, ova, and parasites), sigmoidoscopy, and barium enemas are the most useful diagnostic procedures other than a colonoscopy. Arteriography and gallium scans (for diverticular and other abscesses) and the CT scan have become useful additions to the diagnostic armamentarium. Peritoneoscopy and exploratory laparotomy are still necessary in many cases.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Left Upper Quadrant Mass: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The presence or absence of other symptoms and signs is the key to the clinical diagnosis of an LUQ mass. The presence of jaundice would suggest that the mass is a large spleen. The presence of blood in the stool would suggest carcinoma of the colon. The presence of hematuria would suggest that the mass is renal in origin. An enema should be done to exclude fecal impaction before an extensive workup is performed. A conservative workup will include a CBC, sedimentation rate, urinalysis, chemistry panel, platelet count, stool for occult blood, coagulation profile, and a flat plate of the abdomen. On the basis of these results, the clinician can determine whether to do an upper GI series, barium enema, IVP, or CT scan of the abdomen. Another approach would be to do the CT scan immediately. In the long run, the latter approach may be more cost-effective. It is usually prudent to get a surgical or gastroenterology consult to help decide between the two approaches.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RECTAL MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Anoscopy, sigmoidoscopy, and a barium enema are the most significant tools in the proctologist’s armamentarium. Biopsy or excision of polyps is routine. When one polyp is found, a barium enema or colonoscopy is always done to look for others.

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Source: Differential Diagnosis in Primary Care, 2007

Mediastinal Mass: Mediastinal Mass - DIAGNOSIS
(The 5-Minute Pediatric Consult)

General goal is to establish diagnosis promptly and begin treatment as indicated, because condition may progress rapidly and become life threatening. If you suspect a malignancy, the child should be immediately referred to an oncologist.

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

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