Confirming diagnosis In primary disease, a high concentration of serum PTH on radioimmunoassay with accompanying hypercalcemia confirms the diagnosis.
In addition, X-rays may show diffuse demineralization of bones, bone cysts, outer cortical bone absorption, and subperiosteal erosion of the phalanges and distal clavicles. (See Bone resorption in primary hyperparathyroidism.) Microscopic examination of the bone with tests such as X-ray spectrophotometry typically demonstrates increased bone turnover.Reduced bone mineral density, particularly of the forearm, is seen on bone densitometry.
Laboratory tests reveal elevated urine and serum calcium, chloride, and alkaline phosphatase levels and decreased serum phosphorus levels. Hyperparathyroidism may also raise uric acid and creatinine levels and increase basal acid secretion and serum immunoreactive gastrin. Increased serum amylase levels may indicate acute pancreatitis.
Laboratory findings in secondary hyperparathyroidism show normal or slightly decreased serum calcium levels and variable serum phosphorus levels. Phosphorus can be quite elevated, especially in osteomalacia or renal disease. Patient history may reveal familial renal disease, seizure disorders, or drug ingestion. Other laboratory values and physical examination findings identify the cause of secondary hyperparathyroidism.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Introduction: Malignant Neoplasms:
Diagnostic methods
(Professional Guide to Diseases (Eighth Edition))
A thorough medical history and physical examination should precede sophisticated diagnostic procedures. Useful tests for the early detection and staging of tumors include X-ray, endoscopy, isotope scan, computed tomography scan, and magnetic resonance imaging, but the single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Biopsy tissue samples can be taken by curettage, fluid aspiration (pleural effusion), fine-needle aspiration biopsy (breast), dermal punch (skin or mouth), endoscopy (rectal polyps), and surgical excision (visceral tumors and nodes).
An important tumor marker, carcinoembryonic antigen (CEA), although not diagnostic by itself, can signal malignancies of the large bowel, stomach, pancreas, lungs, and breasts. CEA titers range from normal (less than 5 ng) to suspicious (5 to 10 ng) to suspect (over 10 ng). CEA serves many valuable purposes:
❑as a baseline during chemotherapy to evaluate the extent of tumor spread
❑to regulate drug dosage
❑to prognosticate after surgery or radiation
❑to detect tumor recurrence.
Although no more specific than CEA, alpha-fetoprotein — a fetal antigen uncommon in adults — can suggest testicular, ovarian, gastric, and hepatocellular cancers. Beta human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. Other commonly used tumor markers include prostate-specific antigen to detect and monitor prostatic cancer, and CA-125, useful for monitoring ovarian, colorectal, and gastric cancers.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Malignant spinal neoplasms:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.
❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.
❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)
❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.
❑ Computed tomography scan shows cord compression and tumor location.
❑ Frozen section biopsy at surgery identifies the tissue type.
❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Chvostek's sign:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Obtain a brief history. Find out if the patient has had the parathyroid glands surgically removed or if he has a history of hypoparathyroidism, hypomagnesemia, or malabsorption disorder. Ask him or his family if they have noticed any mental changes, such as depression or slowed responses, which can accompany chronic hypocalcemia.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Thyroid enlargement:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
The patient’s history commonly reveals the cause of thyroid enlargement. Important data include a family history of thyroid disease, when the thyroid enlargement began, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
Begin the physical examination by inspecting the patient’s trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you’ll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient’s neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.
During palpation, be sure to note the size, shape, and consistency of the gland as well as the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit, which is commonly continuous.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Thyroid Enlargement/Goiter:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
In simple goiter, patients are asymptomatic or, if the gland is sufficiently enlarged, they present with symptoms caused by mechanical pressure. Substernal goiters are frequently responsible for tracheal pressure symptoms, including dyspnea and inspiratory stridor. They can also obstruct the large cervical veins at the thoracic inlet, causing suffusion of the face, giddiness, and syncope (Pemberton’s sign). Esophageal compression can lead to dysphagia (Chapter 9.5). Hoarseness caused by compression of or traction on the recurrent laryngeal nerve is rare in simple goiter and suggests a malignancy (Chapter 6.3). Generalized thyroid pain suggests subacute thyroiditis, whereas sudden localized pain and swelling are consistent with hemorrhage into a nodule. Although simple goiters are usually euthyroid, typical symptoms of hypothyroidism or thyrotoxicosis should be sought. A family history of goiter and a personal history of residing in an endemic goiter area or ingesting goitrogens may be significant (1).
Physical examination
A. General examination. Look for typical vital and physical signs consistent with hypothyroidism or thyrotoxicosis. Pemberton’s sign can be induced by having the patient raise both arms above the head.
B. Thyroid examination. Inspect the neck below the thyroid cartilage from the front, using cross-lighting to accentuate shadows and masses. Full extension of the neck enhances visibility of the gland. Inspection from the side with measurement of any prominence of the normally smooth and straight contour between the cricoid cartilage and the suprasternal notch is useful. Palpitation is done using the technique with which the examiner is most experienced and skilled. Approach the patient from either the front or behind and palpate using the fingers or thumbs. If felt between the cricoid cartilage and the suprasternal notch, the thyroid isthmus can be used to help locate the gland. Palpation of the lobes can be improved by relaxation of the sternocleidomastoid; for example, the left lobe can be defined better by having the patient slightly flex and rotate the neck to the left. Other useful maneuvers include measuring the circumference of the neck or the dimensions of each lobe. Note the location, size, consistency, mobility, and tenderness of any nodules. Having the patient swallow during both inspection and palpation causes the thyroid to move and aids in developing a three-dimensional impression of gland shape and size. This maneuver can also make a low-placed gland accessible. Categorize thyroid size as “normal” or “goiter,” and subcategorize “goiter” as “small” (two or less times normal) or “large” (more than two times normal) (2).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Neck Mass/Thyroid Enlargement:
Differential Overview
(Field Guide to Bedside Diagnosis)
Neck Mass
❑ Inflammatory lymphadenopathy
❑ Parotid swelling/tumor
❑ Laryngeal cancer
❑ Intramuscular hematoma
❑ Lymphoma
❑ Nasopharyngeal carcinoma
❑ Branchial cleft cyst
❑ Thyroglossal duct cyst
❑ Supraclavicular adenopathy
❑ Aortic aneurysm
❑ Carotid aneurysm
❑ Ludwig angina
❑ Pharyngeal pouch
❑ Carotid body tumor
Thyroid Enlargement
❑ Simple goiter
❑ Hashimoto thyroiditis
❑ Grave disease
❑ Drugs
❑ Subacute thyroiditis
❑ Thyroid cancer
❑ Infiltrative disease
Diagnostic Approach
Patients often present for evaluation of a “neck mass” that is a normal structure such as the hyoid, and they will insist that it is new or asymmetric.
With thyroid enlargement, the mass will be low in the neck and extend across the midline. Occasionally, a prominent thyroid nodule will mimic a lymph node but is in an atypical location. The thyroid gland rises and falls with swallowing. The only other structure to do this is a thyroglossal duct cyst.
In a multinodular goiter, a malignancy should be suspected when there is a dominant nodule or cervical adenopathy.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Hyper-parathyroidism:
Diagnosis
(Handbook of Diseases)
Findings differ in primary and secondary disease.
Primary disease
In primary disease, a high concentration of serum PTH on radioimmunoassay with accompanying hypercalcemia confirms the diagnosis. In addition, X-rays show diffuse demineralization of bones, bone cysts, outer cortical bone absorption, and subper-iosteal erosion of the phalanges and distal clavicles.
Microscopic examination of the bone with such tests as X-ray spectrophotometry typically demonstrates increased bone turnover. Laboratory tests reveal elevated urine and serum calcium, chloride, and alkaline phosphatase levels and decreased serum phosphorus levels.
Hyperparathyroidism may also raise uric acid and creatinine levels and increase basal acid secretion and serum immunoreactive gastrin. Increased serum amylase levels may indicate acute pancreatitis.
Secondary disease
Laboratory findings in secondary hyperparathyroidism show normal or slightly decreased serum calcium levels and variable serum phosphorus levels, especially when hyperparathyroidism is due to rickets, osteomalacia, or kidney disease. The patient history may reveal familial kidney disease, seizure disorders, or drug ingestion.
Other laboratory values and physical examination findings identify the cause of secondary hyperparathyroidism.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Chvostek's sign:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Obtain a brief history. Find out if the patient has had the parathyroid glands surgically removed or if he has a history of hypoparathyroidism, hypomagnesemia, or malabsorption disorder. Ask him or his family if they have noticed any mental changes, such as depression or slowed responses, which can accompany chronic hypocalcemia. Question the patient about tingling around the mouth and in the fingertips and feet.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Thyroid enlargement:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
The patient’s history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, when the thyroid enlargement began, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Chvostek's sign:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Obtain a brief history. Find out if the patient has had his parathyroid glands surgically removed or if he has a history of hypoparathyroidism, hypomagnesemia, or a malabsorption disorder. Ask him or his family if they have noticed changes in the patient's mental status, such as depression or slowed responses, which can accompany chronic hypocalcemia. Ask the patient if he has experienced any numbness and tingling in his fingers, toes, or around his mouth. Also ask him about muscle twitching or cramping.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Thyroid enlargement:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
The patient's history commonly reveals the cause of thyroid enlargement. Important data includes a family history of thyroid disease, onset of thyroid enlargement, any previous irradiation of the thyroid or the neck, recent infections, and the use of thyroid replacement drugs.
Begin the physical examination by inspecting the patient's trachea for midline deviation. Although you can usually see the enlarged gland, you should always palpate it. To palpate the thyroid gland, you'll need to stand behind the patient. Give the patient a cup of water, and have him extend his neck slightly. Place the fingers of both hands on the patient's neck, just below the cricoid cartilage and just lateral to the trachea. Tell the patient to take a sip of water and swallow. The thyroid gland should rise as he swallows. Use your fingers to palpate laterally and downward to feel the whole thyroid gland. Palpate over the midline to feel the isthmus of the thyroid.
During palpation, be sure to note the size, shape, and consistency of the gland, and the presence or absence of nodules. Using the bell of a stethoscope, listen over the lateral lobes for a bruit. The bruit is often continuous.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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