Physical Diagnosis Exam 4 (Part 2) - Abnormal Findings of the Thyroid & Lymphatics

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What is inflammation of one or more lymphatic vessels, with red streaks marking the affected lymph vessel, occurring proximal to the site of original infection?

Acute Lymphangitis

What is an infection and inflammation of a lymph node, MC from streptococcal and staphylococcal bacterial infection that may affect a single or localized group of nodes?

Acute Suppurative Lymphadenitis

What is edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage?

Lymphedema

What stage of Lymphedema is latent or subclinical, with swelling not evident despite impaired lymph transport?

Stage 0

What stage of Lymphedema is when pitting may occur, and there may be early accumulation of fluid relatively high in protein content, subsidizing with limb elevation?

Stage I

What stage of Lymphedema is when tissue fibrosis is present, and limb elevation alone rarely reduces tissue swelling, pitting may be present, and the limb may or may not pit as tissue fibrosis supervenes?

Stage II

What stage of Lymphedema is when pitting is absent, and trophic skin changes are now present such as acanthosis nigricans, fat deposits, and warty overgrowths?

Stage III

What is the difference between lymphedema or edema?

Early stages: Lymphedema does NOT resolve with elevation of the affected area; Edema secondary to increase capillary filtration usually improves

Diuretics: do NOT help lymphedema but may help edema

NOTE: some patients may have both edema and lymphedema

What is a congenital malformation of dilated lymphatics?

Lymphangioma / Cystic hygroma

What is massive accumulation of lymphedema through the body, caused by parasitic worms in the lymph system, and is the MC cause of secondary lymphedema worldwide?

Lymphatic filariasis (elephantiasis)

What is a malignant neoplasm of the lymphatic system and reticuloendothelial tissue?

Non-Hodgkin lymphoma

What is malignant lymphoma/type of cancer that affects the lymphatic system which is part of the body's germ-fighting immune system, that demonstrates with reed Sternberg cells?

Hodgkin lymphoma

What is an infectious mononucleosis that requires examination of the spleen?

Epstein-Barr virus mononucleosis

What parasitic infection is from zoonosis (via animals) and can cause a single hard non-tender and mobile posterior cervical node and a retinal scarring?

Toxoplasmosis

NOTE: Toxoplasma gondii

What is infection by human herpes virus-6 that MC affects kids between 6 months and 2 years, and is marked by several days of high fever, followed by a distinctive rash just as the fever breaks?

Roseola (HHV-6)

What infection causes skin infections, lasting your lifetime and causing painful or itchy sores/blisters that come and go, but can be dangerous in infants or people with weakened immune systems? What are the 2 types of viruses that cause this?

Herpes Simplex Virus

1) HSV-1

2) HSV-2

What condition is classically demonstrated with axillary lymphadenopathy and is among the MC causes of subacute or chronic lymphadenitis in children?

Cat scratch disease (Bartonella henselae)

What condition is dysfunction of cell-mediated immunity and is the late stage of HIV?

Acquired immune deficiency syndrome (AIDS)

What is an immune-complex-mediated (Type III) hypersensitivity reaction that classically present with fever, rash, polyarthritis, or polyarthalgias?

Serum sickness

What is an allergic contact dermatitis that involves the immune system and is caused by the chemicals used in latex products and is a delayed hypersensitivity?

Immune complex disease / Latex allergic type IV dermatitis

What is a true allergic reaction caused by protein antibodies?

Latex allergy Type I reaction

When it comes to the thyroid and diet, a larger gland will occur in _______-deficient areas, with the upper limit of this mineral being _____-_____gm

Iodine

15-25gm

What are some sources of dietary iodine?

Dairy

(cheese, cow's milk, frozen yogurt, ice cream, yogurt)

Iodine-containing multivitamins an dtable salt

Eggs

Soymilk, Soy sauce

Saltwater fish, Seaweed, Shellfish

T/F: Men have larger and more easily palpable thyroid glands than women

FALSE

women have more larger/easily palpated glands than men

For the thyroid, ________ have larger and more easily palpated thyroid glands, and the _______ lobe is often larger than the other, upt o 1% of the entire ______ lobe can be absent, and a _________ lobe may be present in 21-55% of cases extending as high as the hyoid?

WOMEN

RIGHT

LEFT

PYRAMIDAL

Up to 5% of people have posterior extracapsular tissue, extending superiorly form the posterior aspect of the tongue (non-descent), and extend inferiorly into the mediastinum, called what?

Lingual thyroid

What condition is when thin or long-neckline patients appear to have "pseudo-goiters"?

Modigliani syndrome

Other anterior neck masses may be mistaken for thyroid masses, but how can they be told apart?

Ant. neck masses that are NOT thyroid masses are unlikely to rise with swallowing

The presence of a _______ in the anterolateral neck of a young women and obese patients will NOT rise with deglutination (swallowing)?

Fat Pad

What are the 3 most common causes of False-negative thyroid results? What is the MC cause?

1) Inadequate examination skills (MC)

2) Atypical/ectopic placement of the thyroid (retrosternal, lateral, obscured by the SCMs

3) Short and thick-necked patients, especially the obese or elderly or those with COPD

NOTE: other metabolic issues can also be present when inspecting head and neck, like acanthosis nigricans seen more often in obese & diabetic patients

What is functional thyroid tissue that is located anywhere other than its anatomical position, can be seen lingually?

Ectopic Thyroid

(Lingual thyroid)

What are two major clues of thyroid problems?

Swelling of neck (goitrous) --> hyper/hypo

Exophthalmos (increased prominence of eyes) --> hyper

NOTE: Brachycardia = hypo

What is a chronic enlargement of the thyroid, that is not a neoplastic or inflammatory process, but the result of hypertrophy or degeneration of the gland?

Goiter

T/F: If a goiter is present it usually indicates euthyroid (hyper).

FALSE

Indicates euthyroid (hyper) or dysthyroid (hypo)

T/F: A goiter does not necessarily reflect the functional status of the thyroid

TRUE

Always send for tests, don't assume thyroid malfunction

During pregnancy, the fetal thyroid becomes functional in the ________ trimester. Before this, the mother is the source of the thyroid hormone, so the pregnant women requires increased _________. Due to this, slight enlargement of the _______ may be detectible and is not uncommon on ultrasound.

Second

Iodine

Thyroid (hypertrophy)

In older adults, the rate of _________ gradually decreases with aging, and the thyroid gland becomes more ________.

T4

Fibrotic

What is an underactive thyroid with temperature preference of warm climate, weight gain, lethargic, coarse breaking hair, course/scaling/dry skin, think nails, puffiness in the periorbital region, NO goiter, no changes noted in heart, constipation, and menorrhagia?

Hypothyroidism

What are the 4 types of Hypothyroidism?

Primary

Juvenile

Subclinical

Congenital

What is the characteristic facies of hypothyroidism, with a skin and tissue disorder such as dull, puffy, yellowed skin, coarse sparse hair, temporal loss of eye brows, periorbital edema, and a prominent tongue?

Myxedema Facies

What is an overactive thyroid with temperature preference of cool climate, weight loss, nervous/easily irritated/highly energetic, fine with hair loss and failure to hold a permanent wave, warm fine and hyperpigmented skin, thin fingernails, bilateral or unilateral exopthalmos, goiters in the neck, tachycardia, dysrhythmia, and palpitations, increased frequency of bowel movements, scant menstrual flow, and increasing weakness??

Hyperthyroidism

What is an autoimmune antibodies to thyroid-stimulating hormone receptor, leading to overactive thyroid?

Graves disease

What is an autoimmune antibodies against thyroid gland, often causing hypothyroidism?

Hashimoto disease

What condition occurs when a disorder of the thyroid gland prevents it from producing adequate amounts of thyroid hormone, with symptoms varying, causing metabolic processes to slow down such as fatigue, depression, decreased intellectual function, cold intolerance, dry skin, slowed heart rate, diminished DTR, high cholesterol, mild anemia, and high serum enzymes?

Primary Hypothyroidism

What are the lab levels for Primary Hypothyroidism?

Free T4 LOW

TSH is HIGH

(T3 may be normal)

What is a relatively common disorder for which screening is performed at birth, since the thyroid hormone is necessary for brain development in the first 2 years and is necessary for linear growth, and if absent, can lead to severe brain damage and delayed skeletal maturation?

Congenital Hypothyroidism

What occurs before the age 2 when the thyroid hormone is essential for normal brain development, with the thyroid hormone is essential for normal growth and for bone maturation, thus growth failure, short stature, and delayed bone age is almost always present?

Juvenile Hypothyroisism

Occasionally, what may be enlarged in severe and prolonged juvenile primary hypothyroidism that is presumably due to hyperplasia of the thyrotropes (produce TSH)?

Sella may be enlarged

What is total and free levels of thyroid hormone that are normal, but the TSH is slightly elevated, and there may be a damaged thyroid gland that is unable to meet the needs of the body only with excess stimulation of the pituitary gland and patients usually do not have symptoms of hypothyroidism and do not feel better after most allopathic treatments, with the thyroid gland being normal to palpation or may have a goiter?

"Subclinical" Hypothyroidism

T/F: There is some progress to overt hypothyroidism over time, particularly those with a family history of thyroiditis

TRUE

Summary of Hypothyroidism Conditions:

Primary -->

- Disorder of thyroid gland

- Low T4 and High TSH

- Metabolic processes slow down (fatigue, depression, dry skin, slow heart rate, high cholesterol)

Congenital -->

- Relatively common (screening is performed at birth)

- Causes severe brain damage and delayed skeletal maturation

Juvenile -->

- Stunted cognitive development and growth failure, short stature, and delayed bone age

- Sella may be enlarged

- severe & prolonged juvenile primary hypothyroidism due to hyperplasia of thyrotropes (produce TSH)

Subclinical -->

- Compensated

- Normal T3/4 & TSH is slightly elevated

- NO symptoms of hypothyroidism and does NOT improve w/ most allopathic treatments

- Some progress to overt hypothyroidism w/ family history of thyroiditis

What condition is due to an excess amount of free thyroid hormone, with no generalized increase in metabolic activity including O2 use, and includes heat intolerance, nervousness, decreased menses, hyperkinesis, warm/moist skin, tremors, fast DTRs, cardiac exam?

Hyperthyroidism

What does the labs appear like in hyperthyroidism?

low TSH

high T3 & T4

What is an autoimmune disease in which the immune system produces antibodies which stimulate TSH receptors of the thyroid gland, leading to clinical manifestations of hyperthyroidisms with physical changes such as exophthalmos, proptosis, dry/burning eyes, and pretibial myxedema (skin thickening on legs)?

Graves' Disease (Autoimmune Hyperthyroidism)

What ae 3 major manifestations of Grave's Disease?

1) Hyperthyroidism with a diffuse goiter

2) Ophthalmopathy (exophthalmos)

3) Dermopathy (pretibial myxedema)

What is characterized by an insidious symmetrical enlargement of the thyroid, which becomes firm but not painful, with antithyroglobulin antibody and ant microsomal antibody titers usually high, with NO antibody against TSH and leads to gradual development of hypothyroidism?

Hashimoto's Disease (Autoimmune Hypothyroidism)

In Hashimoto's Disease, thyroid acini are almost replaced by what?

B lymphocytes

What is an autoimmune disease that may cause digital clubbing and periostitis but is usually asymptomatic in those who have been thyrotoxic?

Thyroid Acropachy

What can be due to a primary failure of the pituitary gland or as a result of hypothalamus dysfunction?

Secondary hypothyroidism (Hypopituitarism)

T/F: Antibody titers rarely tested on regular thyroid panel, so it often goes undiagnosed until it has progressed

TRUE

What is a neural tube defect with protrusions of the brain and membranes that cover it through openings in the skull?

Encephalocele

What is a problem in the formation, flow, or absorption of cerebrospinal fluid (CSF) that leads to an increase in volume of the CSF?

Hydrocephalus

What is a smaller than normal head circumference because the brain has not developed properly or has stopped growing?

Microcephaly

What is asymmetrical appearance of the skull due to repeated pressure on one side of the head?

Plagiocephaly

What is premature closing of one or more cranial sutures before brain growth is complete, leading to a misshapen skull?

Craniosynostosis

Unilateral swelling of the salivary glands is usually due to what? If this is a painless unilateral swelling, what is it often?

Ductal calculus due to infection (staph or strep)

Tumor

What are possible indicators of bilateral salivary gland swelling?

Malnutrition

Sjorgrens syndrome

Alcoholism

Diabetes mellitus

HIV

Thyrotoxicosis

Leukemia & Lymphoma

Drugs

Acute parotitis (mumps)

Cervical Adenitis

What is the difference between Mumps and Cervical Adenitis?

Cervical adenitis does NOT ordinarily obscure the angle of the jaw

What is a palpable cystic mass in the midline of the neck that may cause tenderness, redness, swelling at the neck, and the patient may have difficulty swallowing/breathing, with a freely moveable mass that moves upward with tongue protrusion & swallowing and may have mucus drainage through small surficial opening?

Thyroglossal duct cyst

What is a congenital lesion formed by incomplete involution of brachial cleft on the lateral aspect of the neck, along the anteromedial border of the SCM, that is usually painless with intermittent swelling and tenderness, but can have some pain or discharge IF associated with sinus tract, while being an oval, movable, smooth, non-tender fluctuant mass that is generally asymptomatic (unless infected w/ redness/swelling)?

Brachial cleft cyst

What is shortening and excessive contraction of the SCM, due to birth trauma, tumors, trauma, CN palsy, muscle spasms, infection, drug ingestion?

Torticollis (Wry neck)

What is a protrusion of mucous membrane through the wall of the larynx due to a hernia of the larynx, filled with gas from the laryngeal saccules and is asymptomatic when small but is almost exclusively unilateral?

Laryngocele

What is a protrusion of mucous membrane through the wall of the pharynx due to a hernia of the pharynx filled with gas form piriform sinuses and is MC asymptomatic and can be unilateral or bilateral?

Pharyngocele

What are the risk factors of a laryngocele? Pharyngocele?

RAISED INTRALARYNGEAL PRESSURE

(from excessive cough, wood instrument, glass blowing, or obstructing lesion/tumor)

INCREASED INTRA-PHARYNGEAL PRESSURE

- woodwind instrument/glass blowing (Occupational overuse syndrome)

What is the fluctuant, movable, air-filled, non-tender lump?

Brachial Cleft Cyst

What is a goitrous (swollen) non-tender, moving with swallowing mass?

Goiter

What is a moveable, fluid-filled, red, warm, and tender lump?

Infected Cyst

What is a warm, tender, pus-filled, may be erythematous neck lump?

Deep cervical abscess

What is a hard, immobile, non-tender neck lump?

lymph node metastasis

What is a warm, tender, pus-filled lump that may be erythamtous?

Submandibular abscesses

What are some red flags for head injury? (4)

History of loss of consciousness

Predisposing factors (seizures/syncope)

Associated symptoms like pain, vision changes, nasal discharge (CSF)

Medications

What are the red flags about headaches?

OPQRST

What are the red flags for stiff neck? (4)

injury

swelling

fever

medication

What are the red flags for thyroid problems? (6)

Change in temperature

Dysphagia

Pain

Hair/skin changes

Lethargy

Menstrual flow problems

What is a common pain in the head and one of the most self-medicated conditions?

Headaches

What is the age of onset for a migraine? What is the location? Quality of pain?

Childhood

Unilateral or generalized

Pulsating or throbbing

What is the duration of migraines? Time of onset?

Hours to days

Morning or night

What is the predromal events for migraines? (8)

Vague neurological changes

Personality change

Fluid retention

Appetite loss to well-defined neurologic event

Scotoma

Aphasia

Hemianopsia

Aura

What are the precipitating events of a migraine?

Menstrual period

Missing meals

Birth control pills

Letdown after stress

What is the frequency of migraines? Gender predilection? Other symptoms?

2x a week

Females

N/V

What is the age of onset for Medicated rebound headaches? Location? Quality of pain?

Any age

Generalized or diffuse

Dull or throbbing

What is the time of onset for medicated rebound? Duration of pain?

Predictably begins w/in hours to days of last dose of medication/coffee

Hours to days

What are the prodromal events for medication rebound headaches?

Daily analgesics use and/or daily caffeine use

What are the precipitating events for medication rebound?

Abrupt discontinuation of analgesics or caffeine

What are the frequency of medication rebound headaches? Gender preference? Other symptoms?

Gradual increase in headache frequency to daily

Female

Alternate or preventative medications fail to control headache

What are the age of onset for cluster headaches? Location? Quality of pain?

Adulthood

Unilateral

Intense burning, boring, searing, knifelike pain

What is the duration of cluster headaches? Time of onset?

0.5 to 2 hours

Night

What is the prodromal event for cluster headaches? (2)

Personality changes, sleep disturbances

What is the precipitating even for cluster headaches?

Alcohol consumption

What is the frequency of cluster headaches? Gender preference? Other symptoms?

Several times nightly for several nights, then none

Males

Increased lacrimation, nasal discharge