Sandbox: hyperthyroidism 2

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Differentiating hyperthyroidism from other diseases

Disease Prominent clinical features Lab findings Imaging
Hyperthyroidism The main symptoms include:
  • The patient usually has elevated T3 and T4
  • TSH might be increased or decreased depending on the underlying cause
  • Thyroid stimulating antibodies (TSI) might be increased in cases of Graves’ disease
By Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center - The Eyes Have It, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=16115992
Essential hypertension Most patients with hypertension are asymptomatic at the time of diagnosis. Common symptoms are listed below: JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension:[1]
  • 12-Lead electrocardiogram (ECG)
  • Urinalysis, including urinary albumin excretion or albumin/creatinine ratio
  • Blood glucose
  • Blood hematocrit
  • Serum electrolytes, especially potassium
  • Serum calcium
  • Lipid profile: Total cholesterol, LDL, HDL, triglycerides
  • Creatinine or equivalent to assess estimated GFR
Arrhythmia
Generalized anxiety disorder DSM-V Diagnostic Criteria for Generalized Anxiety Disorder[2]
  • A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school

performance).

AND

  • B. The individual finds it difficult to control the worry.

AND

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months);

Note: Only one item is required in children.

  • 1. Restlessness or feeling keyed up or on edge.
  • 2. Being easily fatigued.
  • 3. Difficulty concentrating or mind going blank.
  • 4. Irritability.
  • 5. Muscle tension.
  • 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

AND

  • D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

  • E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g.,hyperthyroidism).

AND

reminders of traumatic events in post traumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Menopausal symptoms The perimenopause symptoms are caused by an overall drop, as well as dramatic but erratic fluctuations, in the levels of estrogens, progestin, and testosterone. Some of these symptoms such as formication etc, may be associated with the hormone withdrawal process.

Vasomotor instability

Urogenital atrophy

Skeletal

Skin, soft tissue

  • Breast atrophy
  • Skin thinning
  • Decreased elasticity
  • Formication, a sensation of pins and needles, or ants crawling on or under the skin

Psychological

Sexual

  • B-HCG should always be done first to rule out pregnancy especially in women under the age of 45 years
  • FSH can be measured but it can be falsely normal or low
  • TSH, T3 and T4 to rule out thyroid abnormalities
  • Prolactin can be measured to rule out prolactinoma as a cause of menopause
Opioid withdrawal disorder

DSM-V Diagnostic Criteria for Opioid Withdrawal[3]

  • A. Presence of either of the following;
  • 1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e.,several weeks or longer).
  • 2. Administration of an opioid antagonist after a period of opioid use.

AND

  • B. Three (or more) of the following developing within minutes to several days after Criterion A:

AND

  • C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

  • D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
  • Urine drug screen to rule out any other associated drug abuse
  • Routine blood work such as electrolytes and hemoglobin to rule out any associated disease explaining the symptoms
Pheochromocytoma The hallmark symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, symptoms usually subside in less than one hour and they may include:

Please note that not all patients with pheochromocytoma experience all classical symptoms.

Diagnostic lab findings associated with pheochromocytoma include:
Left sided pheocromocyroma - Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 44813
  1. Cuddy ML (2005). "Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1)". J Pract Nurs. 55 (4): 17–21, quiz 22-3. PMID 16512265.
  2. Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  3. Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  4. Bravo EL, Gifford RW (1993). "Pheochromocytoma". Endocrinol Metab Clin North Am. 22 (2): 329–41. PMID 8325290.