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Diseases » Obesity » Tests
 

Diagnostic Tests for Obesity

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

Obesity: Diagnostic Tests

The list of diagnostic 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 Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Obesity:

Obesity Diagnosis: Book Excerpts

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.

Body Mass Index Table

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 of Obesity:

Diagnostic Tests for Obesity: Online Medical Books

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

OBESITY, PATHOLOGIC: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FEMORAL MASS OR SWELLING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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

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.

» READ BOOK EXCERPT ONLINE »

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

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.)

» READ BOOK EXCERPT ONLINE »

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

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

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.

Testing

 A. Clinical laboratory tests will depend on the index of suspicion, based on the most common diagnoses in the anatomic location. These may include complete blood count, erythrocyte sedimentation rate, lactic dehydrogenase, alpha fetoprotein, beta fraction human growth hormone, serum calcium, parathormone, gamma globulins, serum antiacetylcholine receptor antibody, purified protein derivative skin test, and HIV antibody screening.

 B. Imaging studies. Any patient, but especially smokers or exsmokers, with unexplained peripheral adenopathy, unexplained cough, or any of the aforementioned symptoms, should have a chest x-ray study after no more than 2 to 3 weeks of symptomatic treatment. Any mediastinal mass seen requires a CT with iodinated bolus. The indications for mediastinal MRI are suspected vascular lesion, equivocal CT findings, posterior or paravertebral masses and neurogenic tumors, and suspected tumor recurrence so that scarring can be delineated from tumor. The MRI should be ordered with T1- and T2-weighted images and gadolinium-enhanced T1 images.

Diagnostic assessment

Correlation of the clinical and imaging picture is paramount in deciding the extent of the investigation of a mediastinal mass, because of the fairly predictable location pattern of various lesions. A patient with acute, searing chest pain and mediastinal widening will need emergent attention for thoracic aortic dissection. An anterior solid mass in a patient with cough and weight loss demands a tissue diagnosis and, if operable, surgical extirpation. A posterior cystic mass in a healthy patient may allow close follow-up. However, much overlap is seen (6), and diagnostic accuracy is better based on direct clues (e.g., tissue diagnosis) and on solid clinical judgment to include surgical diagnosis or treatment or medical or oncologic methods, if inoperable.


References

1. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors. Part I: Tumors of the anterior mediastinum. Chest 1997;12(2):511–522.

2. Giron J, Fajadet P, Sans N, et al. Diagnostic approach to mediastinal masses. Eur J Radiol 1998;27(1):21–42.

3. Laurent F, Latrabe V, Lecesne R, et al. Mediastinal masses: diagnostic approach. Eur Radiol 1998;8(7):1148–1159.

4. Mediastinal or hilar enlargement. In: Burgener FA, Kormano M. Differential diagnosis in conventional radiology, 2nd revised ed. London: Thieme Medical Publishers, 1991.

5. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors. Part II. Tumors of the middle and posterior mediastinum. Chest 1997;112(5):
1344–1357.

6. Ahn JM, Lee KS, Goo JM, Song KS, Kim SJ, Im JG. Predicting the histology of anterior mediastinal masses: comparison of chest radiography and CT. J Thorac Imaging 1996;11(4):265–271.

» READ BOOK EXCERPT ONLINE »

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

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

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).

Testing

Either radioisotope scans or color Doppler ultrasound can be used to confirm or rule out testicular torsion. Specificities of 95% and 97% are reported (2). False-negative results do occur, however, producing lower sensitivities (86% and 80%, respectively) (2). In this series, most false-negative results occurred either in cases of prolonged torsion in which the testicles were no longer salvageable or in cases of intermittent torsion. Ultrasound can be helpful in differentiating some masses (e.g., hydrocele from solid mass, testicular from extratesticular). However, ultrasound showed a disappointing ability to differentiate malignant from benign masses in children (4). Aspiration of a spermatocele usually reveals dead sperm (1). Pyuria is almost always present in epididymitis, but it has also been found in up to 27% of patients with torsion ( >five white blood cells per high power field) (5). Similarly, leukocytosis suggests an infectious cause but it has also been found in 33% of patients with torsion (5).

Diagnostic assessment

Each type of scrotal mass has a typical presentation, and most can be readily diagnosed based on history and physical examination. However, considerable overlap is seen in the presentation and laboratory or imaging studies of these conditions, which makes establishing a diagnosis challenging in some cases. If the diagnosis of testicular torsion cannot be rapidly and confidently excluded, emergent referral is strongly recommended. If testicular torsion is not suspected but a diagnosis is not clear after the history, physical examination, and appropriate studies, less urgent consultation is recommended.


References

1. Junnila J, Lassen P. Testicular masses. Am Fam Physician 1998;57:685–692.

2. Lewis AG, Bukowski TP, Jarvis PD. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30:277–282.

3. Son KA, Koff SA. Evaluation and management of the acute scrotum. Prim Care 1985;6:637–646.

4. Aragona F, Pescatori E, Talenti E. Painless scrotal masses in the pediatric population: prevalence and age distribution of different pathological conditions—a 10-year retrospective multicenter study. J Urol 1996;155:1424–1426.

5. Kattan S. Spermatic cord torsion in adults. Scand J Urol Nephrol 1994;28:277–279.

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

Obesity: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

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

Perform a complete physical examination. Don’t restrict the examination to the patient’s abdomen because you could miss important clues to the cause of his abdominal distention. 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 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, and 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 abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.

» READ BOOK EXCERPT ONLINE »

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

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

  • 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.

    • » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Obesity

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