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Antithyroid drugs include methimazole and propylthioura-
cil (PTU). Use of these medications for 12–18 months results
in remission in 40–50% of patients [13]. Both of these medica-
tions decrease hormone synthesis by interfering with thyroid
peroxidase (TPO). Methimazole is the preferred primary
treatment for most patients, as PTU has been associated with
hepatotoxicity. PTU is utilized in the first trimester of preg-
nancy and in patients intolerant to methimazole. The starting
dose of methimazole is 10–30 mg a day, generally in a single
dose, and thyroid function tests are performed within
2–6 weeks. Duration of therapy is approximately 12–18 months,
followed by a taper if the patient is felt to be in remission.
Adverse effects of the antithyroid drugs include pruritic rash
and arthralgias (5%). Agranulocytosis occurs in 1 in 500
patients [14] and typically presents with fever and pharyngitis.
Patients taking antithyroid drugs should be warned about this
potential side effect. Checking routine white blood cell counts
is controversial, though roughly 50% of prescribers routinely
check CBCs of patients on thyroid medications [15].
Radioactive Iodine (RAI)
The goal of RAI is to render the patient hypothyroid. RAI
is incorporated into thyroid hormone, which causes damage
to follicular cells and eventual destruction of the thyroid
gland. Most patients develop hypothyroidism 2–3 months
after a single dose of RAI is administered. Serial thyroid hor-
mone measurements should be done at 2–6-week intervals
and levothyroxine therapy initiated when free T4 levels drop
below normal range.
Surgery
Indications for surgery include large goiters with compres-
sive symptoms, suspicious thyroid nodules, and hyperparathy-
roidism [16].
Treatment: Subclinical Hyperthyroidism
The need for treatment in subclinical hyperthyroidism is
controversial but may be advised in patients with persis-
tently suppressed TSH (<0.10), the elderly, or those with
cardiac disease, particularly since the risk of atrial fibrillation
is higher in these groups.
8. Thyroid Dysfunction
162
Clinical Pearls
• Graves’ disease is the most common cause of hyperthy-
roidism, accounting for 75% of cases, and is mediated by
antibodies to the thyroid-stimulating hormone (TSH)
receptor.
• Older patients tend to have fewer symptoms of
hyperthyroidism.
• Consider treatment of subclinical hyperthyroidism in
patients over the age of 65 with persistently suppressed
TSH and cardiac history.
Don’t Miss This!
• Agranulocytosis occurs in roughly 1/500 patients treated
with antithyroid medications, and patients should be
alerted to the signs and symptoms of this side effect (fever,
sore throat, oral ulcers).
• In older patients, TSH should be measured in the setting of
new-onset atrial fibrillation.
Thyroid Nodules
Introduction
The identification of thyroid nodules can occur by several
means. The patient may note a change in the neck, or a
clinician may identify a nodule on physical exam.
Additionally, thyroid nodules may be noted incidentally
when patients undergo imaging (ultrasound, CT scanning,
etc.) for other reasons. Palpable thyroid nodules are found
in 4–7% of the population [17], whereas ultrasound may
detect nodules in 19–68% of a random population sample
[18]. When evaluating thyroid nodules, it is important to
exclude thyroid malignancy, which can occur in 7–15% of
thyroid nodules [19].
N.A. LaVi n e
163
Key H&P
Thyroid nodules are often asymptomatic. Important history
to obtain in a patient with a thyroid nodule includes history
of radiation treatment to the head or neck, family history of
thyroid cancers, neck discomfort, rapid growth of the nod-
ule, dysphagia, and hoarseness. Exam should focus on the
thyroid, with special attention to the adjacent lymph nodes
of the neck.
Decision-Making/Differential Diagnosis
The presence of a nodule on exam should be further evalu-
ated with ultrasonography of the neck and a serum TSH [17,
19]. If the TSH is below normal (suggesting hyperthyroid-
ism), the nodule should be assessed for hyperfunctioning
with a radioiodine scan. Hyperfunctioning nodules are
rarely malignant, and further workup would include a free
thyroxine level and treatment for hyperthyroidism as appro-
priate. If the nodule is nonfunctional, the characteristics of
the nodule will dictate further workup, including possible
fine needle aspiration (FNA). If the TSH is normal or ele-
vated, the characteristics of the nodule will influence further
workup (Fig. 8.3).
Treatment
If FNA is performed, further testing and diagnosis will be
dependent on the results and may include observation or
surgical thyroidectomy [19].
Clinical Pearls
• Thyroid nodules are common in the general population,
most are benign.
• Thyroid ultrasound and TSH measurement are the main
factors in guiding diagnosis.
8. Thyroid Dysfunction
164
Don’t Miss This!
• Ultrasound characteristics of suspicious thyroid nodules
include solid hypoechoic nodules with irregular margins,
microcalcifications, and extra-thyroidal extension.
References
1. Tunbridge WM, Evered DC, Hall R, et al. The spectrum of
thyroid disease in a community: the Whickham survey. Clin
Endocrinol. 1977;7:481–93.
2. Vanderpump MP, Tunbridge WM, French JM, et al. The inci-
dence of thyroid disorders in the community: a twenty-year
follow-up of the Whickham Survey. Clin Endocrinol. 1995;43:55.
3. https://www.imshealth.com/files/web/IMSH%20Institute/
Reports/Medicines_Use_and_Spending_Shifts/Medicine-
Spending-and-Growth_1995-2014.pdf.
4. Biondi B, Wartofsky L. Treatment with thyroid hormone. Endocr
Rev. 2014;35(3):433–512.
Thryoid Nodule
on Ultrasound
TSH
Suppressed
Hyperfunctioning
Nodule
Check Free T4
and T3; treat for
Hyperthyroidism
as appropriate
Non/
Hypofunctioning
Nodule
Size <1 cm
Low Risk
features:
No Family Hx
Age >60
Well defined
margins
Cystic lesions
Radionuclide
Scanning
Evaluate
Sonographic
Characteristics
TSH Normal
or Elevated
Consider
Observation
Size ≥1 cm
and/or
suspicious
features:
Solid hypoechoic
Irregular margins
Calcifications
Extrathyroidal
extension
Size
≥1.5cm
FNA
FNA
Fig. 8.3 Diagnostic algorithm for thyroid nodules
N.A. LaVi n e
165
5. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The col-
orado thyroid disease prevalence study. Arch Intern Med.
2000;160(4):526–34.
6. Canaris GJ, Steiner JF, Ridgway EC. Do traditional symp-
toms of hypothyroidism correlate with biochemical dis-
ease? J Gen Intern Med. 1997;12(9):544–50. https://doi.
org/10.1046/j.1525-1497.1997.07109.x.
7. Roberts CG, Ladenson PW. Hypothyroidism. Lancet.
2004;363:793–803.
8. Biondi B, Klein I. Hypothyroidism as a risk factor for cardiovas-
cular disease. Endocrine. 2004;24:1–13.
9. Roos A, Linn-Rasker SP, van Domburg RT, Tijssen JP, Berghout
A. The starting dose of levothyroxine in primary hypothyroidism
treatment: a prospective, randomized, double-blind trial. Arch
Intern Med. 2005;165:1714–20.
10. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter
EW, Spencer CA, Braverman LE. Serum TSH, T(4), and thy-
roid antibodies in the United States population (1988 to 1994):
National Health and Nutrition Examination Survey (NHANES
III). J Clin Endocrinol Metab. 2002;87(2):489–99.
11. Nyström HF, Jansson S, Berg G. Incidence rate and clinical
features of hyperthyroidism in a long-term iodine sufficient
area of Sweden (Gothenburg) 2003–2005. Clin Endocrinol.
2013;78:768–76.
12. Burch HB, Burman KD, Cooper DSA. A 2011 survey of clinical
practice patterns in the management of Graves’ disease. J Clin
Endocrinol Metab. 2012;97(12):4549–58.
13. Sundaresh V, Brito JP, Wang Z, et al. Comparative effective-
ness of therapies for Graves’ hyperthyroidism: a systematic
review and network meta-analysis. J Clin Endocrinol Metab.
2013;98(9):3671–7.
14. Nakamura H, Miyauchi A, Miyawaki N, Imagawa J. Analysis of
754 cases of antithyroid drug-induced agranulocytosis over 30
years in Japan. J Clin Endocrinol Metab. 2013;98(12):4776–83.
15. Burch HB, Burman KD, Cooper DSA. A 2011 survey of clinical
practice patterns in the management of Graves’ disease. J Clin
Endocrinol Metab. 2012;97(12):4549–58.
16. Bahn Chair RS, Burch HB, Cooper DS, American Thyroid
Association; American Association of Clinical Endocrinologists,
et al. Hyperthyroidism and other causes of thyrotoxicosis:
management guidelines of the American Thyroid Association
and American Association of Clinical Endocrinologists. Thyroid.
2011;21(6):593–646.
8. Thyroid Dysfunction
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17. Burman K, Wartofsky L. Thyroid nodules. N Engl J Med.
2015;373:2347–56.
18. Tan GH, Gharib H. Thyroid incidentalomas: management
approaches to nonpalpable nodules discovered incidentally on
thyroid imaging. Ann Intern Med. 1997;126:226–31.
19. Haugen BR, Alexander EK, Bible KC, et al. American Thyroid
Association Management Guidelines for adult patients with
thyroid nodules and differentiated thyroid cancer: the American
Thyroid Association Guidelines Task Force on thyroid nodules
and differentiated thyroid cancer. Thyroid. 2016;26(1):1–133.
N.A. LaVi n e
167© Springer International Publishing AG 2018
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-319-68379-9_9
Introduction
Obesity is a chronic, relapsing, multifactorial, neurobehav-
ioral disease, wherein an increase in body fat promotes adi-
pose tissue dysfunction and abnormal fat mass resulting in
adverse metabolic, biomechanical, and psychosocial health
consequences [1]. Obesity is defined as having a body mass
index (BMI) of ≥30 kg/m
2
. It is estimated that more than 1
billion of the world’s population are obese. This significant
prevalence of obesity poses public health as well as economic
concerns.
In 2014, 36.5% of the US population was considered to be
obese [2]. Obesity is associated with an increased risk for devel-
oping many common chronic medical conditions. According to
Chapter 9
Obesity
Gayotri Goswami and Jacinth S. Ruddock
G. Goswami, MD, FACE
Division of Endocrinology and Metabolism, Department of
Medicine, North Central Bronx Hospital,
3424 Kossuth Ave, Bronx, NY 10467, USA
e-mail: Gayotri.Goswami@nychhc.org
J.S. Ruddock, MD (*)
Department of Internal Medicine, North Central Bronx Hospital,
3424 Kossuth Ave, Suite 3H-17, Bronx, NY 10467, USA
e-mail: Jacinth.Ruddock@nychhc.org
168
data from the 2012 National Ambulatory Medical Survey, there
were 11 million visits by adults age >20 years old to a physi-
cian’s office where obesity was listed as a primary diagnosis [3].
An additional chronic medical condition was associated with
73% of these visits [3]. Primary care physicians are faced with
the challenge of screening for and treating obesity and its
related complications. The USPSTF recommends screening all
adults for obesity and treating those with a BMI of >30 kg/m
2
[4]. The primary care provider is integral to getting patients
engaged in the conversation about weight loss. However, pri-
mary care providers cite limited time, inadequate knowledge of
obesity treatment, and lack of reimbursement as reasons obe-
sity is not addressed [5].
This text hopes to aid in bridging the knowledge deficit.
We provide a review of current best practices for medical
evaluation and management of patients with obesity.
Approaches to the conversation about weight management
and algorithms for treatment will be highlighted.
Key History and Physical Exam
History
Starting the conversation about weight loss is important.
Patients considered even a brief conversation with their pri-
mary care provider about how weight loss may improve their
health to be motivating, helpful, and appropriate [6]. As with
most health issues, the conversation should be broached sen-
sitively. Utilize a strategy that focuses on information sharing
rather than blaming patients for their weight. Recognize
obesity as a medical condition by using language that is
agreeable, inoffensive, and clear [7]. The terms fat, obese, and
morbidly obese are most associated with stigmatization and
blaming, while the terms overweight or unhealthy weight are
more acceptable and motivating [8].
Taking an obesity-focused history includes assessment of
historical events surrounding weight gain or loss, paying close
G. Goswami and J.S. Ruddock
169
attention to the patient’s own perception of weight. Major
life events that may contribute to weight gain include changes
in marital status or employment status, quitting tobacco,
pregnancy, and menopause. These events can be plotted on a
weight graph to aid in presenting a visual depiction of the
trends [7]. The review of medical history should be thorough
and include any history of childhood or adolescent obesity.
Assess for any symptoms or signs suggestive of secondary
causes of weight gain. For example, a body habitus suggestive
of a specific hormone imbalance or genetic anomaly might
prompt further testing. A careful review of all medications
should be completed in order to identify and modify any
drugs or substances known to promote weight gain. Common
weight-inducing prescription medications include beta-block-
ers, oral corticosteroids, sulfonylureas, insulin, atypical anti-
psychotics, and hormonal treatments such as progesterone.
Assessment of psychological health including a thorough
psychiatric history is essential. Assess for mood or anxiety disor-
ders, eating disorders, post-traumatic stress disorder, psychotic
disorders, and substance abuse disorders. Any positive findings
should trigger a mental health referral for further assessment
prior to initiating any weight management treatment [7].
Assessment of readiness to engage in a weight manage-
ment regimen should be evaluated. Readiness is primarily
determined by the patients’ level of motivation and the feasi-
bility of implementing and adhering to a weight-loss plan.
Identifying and addressing patient-specific barriers are criti-
cal in order for patients to achieve their weight-loss goals.
Clarify the patient’s expectations and goals and reconcile
them with the physician’s medical recommendations. It is
possible that it may not be the optimal time for the patient to
undertake a weight-loss plan. The patient may still be in the
pre-contemplative or contemplative stages of behavior
change, and physician counseling may serve to catapult them
to a stage of readiness to engage in weight-loss activities.
Physicians’ use of the 5As approach (Assess, Advise, Agree,
Assist, Arrange) has been found to lead to improved weight-
loss outcomes [9].
9. Obesity
170
Physical Examination and Diagnostics
The focus should be on further assessment for objective find-
ings to quantify and qualify obesity, to determine if any
comorbid conditions or secondary contributors to obesity
exist, and to direct specific screening or diagnostic testing.
Patients who are obese may experience a great amount of
trepidation when seeking medical care as many offices do not
have the appropriate instruments readily available for an
accurate and comfortable examination [10]. Always use suit-
able instruments for a patient’s body habitus especially when
measuring weight and blood pressure. Often examination
gowns/drapes and tables may be too small. These factors may
limit the comfort of the patient and also the usefulness and
even safety of proceeding with the exam.
Calculate BMI based on an accurate height and weight.
Measurement of waist circumference provides additional infor-
mation regarding predisposition to metabolic disease among
individuals with BMI <35 kg/m
2
[7, 11]. Percentage of body fat
may be more useful in patients at the extremes in muscle mass
and may be a more accurate measure of body composition.
Assess blood pressure using an appropriately sized cuff.
Examine the skin for signs suggestive of glucose intolerance
such as acanthosis nigricans. Conduct a thorough cardiorespira-
tory, abdominal, and musculoskeletal exam (Table 9.1).
Table 9.1 Weight classifications based on BMI
Weight Body mass index (BMI), kg/m
2
Normal 18.5–24.9
Overweight 25.0–29.9
Class 1 obesity 30.0–34.9
Class 2 obesity 35.0–39.9
Class 3 obesity ≥40
G. Goswami and J.S. Ruddock