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Flashcards in Endocrinology Deck (10):
1

What are the components of the neck exam?

Note: may be thyroid, SVC obstruction, LN, carotid aneurysm, bruits, tracheal deviation

Observation
- Hyper/hypothyroidism changes
- Inspect neck from front and from side (with swallowing)
- Hoarseness (recurrent laryngeal nerve)

Palpate
- Nodes (with swallowing)
- Tender ?thyroiditis
- Lower border of thyroid
- Thyroid thrills
- Cervical LN
- Carotid arteries
- SCM function (?malignant infiltration)
- Tracheal position

Percuss
- Manubrium and paramedially (?retrosternal extension)

Listen
- Thyroid bruits
- Carotids (flow mumur in thyrotoxicosis)

Pemberton's sign

Eyes
- Exophthalmos (from behind), lid retraction, lid lag
- Chemosis (thyrotoxicosis)
- Ophthalmoplegia: inferior oblique first (external rotation, elevation, abduction), then convergence, then others
- Fundoscopy: optic atrophy

Face
- General swelling, periorbital oedema
- Loss of outer third of the eyebrows
- Chvostek's sign if thyroidectomy scar
- Tongue: macroglossia
- Sensorineural deafness

Hands
- Tremor
- Dry, cool skin
- Peripheral cyanosis
- Thyroid acropachy
- Onycholysis
- Palmar erythema, warmth, sweating
- Pallor of the palmar creases


Upper limbs
- Carpal tunnel syndrome
- Radial pulse (tachycardia/bradycardia), AF, collapsing pulse
- Proximal myopathy
- Reflexes: briskness or slow relaxing

Chest
- Gynaecomastia
- ES murmur or CCF
- Pleural/pericardial effusions in hypothyroidism

2

What are the DDx for gynaecomastia?

- Persistent pubertal gynaecomastia
- Drugs (spironolactone, ketoconazole, hCG, antiandrogens, GnRH, 5 alpha-reductase inhibitors, omeprazole, ranitidine, ACEIs, CCB, digoxin, methyldopa, TCAs, haloperidol, phenothiazines, atypical antipsychotics, diazepam, metoclopramide, phenytoin)
- EtOH, marijuana, methadone

3

Acromegaly:
- Ix
- Mx
- Cx

Ix: IGF-1 => if elevated, OGTT => if inadequate suppression, pituitary MRI => if normal, CT chest/abdo and GHRH level

Mx: Trans-sphenoidal pituitary surgery => dopamine agonists (cabergoline), somatostatin receptor agonists (octreotide), or pegvisomant (GH receptor antagonist)

Cx: carpel tunnel, peripheral neuropathy, arthritis/arthralgias, OSA, DM, headache, sweating, galactorrhoea

4

What are the clinical signs of acromegaly?

Hands: thickened skin, large hands, finger pricks, OA, pseudogout, sweaty hands, carpel tunnel syndrome, peripheral neuropathy, Tinnel's/Phalen's signs

Upper limbs: thickened ulnar nerve, proximal myopathy

Axillae: acanthosis nigricans, skin tags

Face: prominent brow, large nose, macrognathia, macroglossia, widely-spaced teeth, acne, low husky voice

Eyes: Visual field defects, angioid streaks/DM/HTN on fundoscopy

Neck: goitre

Chest: Gynaecomastia (hypopit), CCF

Abdo: organomegaly

Testes: small testes

Lower limbs: OA, pseudogout, entrapment neuropathy, heel pad thickening

Other: PR (rectal ca), U/A (glucose), BP (HTN)

5

What are the components of the hypopituitarism examination?

Inspection
- Short stature
- Absence of body hair
- No secondary sexual characteristics

Face
- Fine wrinkling around mouth and eyes in GH deficiency
- Hypophysectomy scar on inner canthus

Eyes
- Visual field defects
- Optic atrophy
- Cavernous sinus signs (III, IV, V1, VI)

Chest
- Pallor
- Lack of hair
- Gynaecomastia

Pelvic
- Testicular atrophy
- Absence of pubic hair

Lower limbs
- Slow relaxing ankle jerks (hypothyroidism)

BP
- Low in cortisol deficiency

6

What are the components of the Cushing's exam?

Inspection
- From in front, sides and behind
- Central obesity with peripheral sparing
- Skin bruising, atrophy, pigmentation (ectopic ACTH, or bilateraly adrenalectomy)

MSK
- Arms and legs
- Buffalo hump
- Spinal tenderness

Face
- Moon facies
- Plethora
- Telangiectasia
- Acne
- Hirsutism
- Orla thrush

Eyes
- Visual field defects
- Fundi: papilloedema, HTN/DM changes, optic atrophy

Neck
- Supraclavicular fat pads
- Acanthosis nigricans

Chest and abdomen
- Gynaecomastia (adrenal cancer)
- Striae
- Adrenalectomy scars
- Adrenal masses

Genitalia
- Virilsation in females (adrenal cancer)

Lower limbs
- Oedema
- Bruising
- Infected ulcers

Extra
- U/A: glucose
- BP (HTN)

7

What are the signs of disease activity in acromegaly?

Number of skin tags
Excessive sweating
Presence of glycosuria
Increased visual field loss
CN palsies of III, IV, VI, V
Enlarging goitre
HTN
Headache, increasing ring size, shoe size or dentures

8

What are the components of the Addison's examination?

Observation
- Pigmentation: palmar creases, elbows, gums, buccal mucosa
- Vitiligo
- Ear lobe calcification

BP
- Postural drop

9

What are the components of the diabetic examination?

Inpection
- Cushing's, acromegaly, haemochormatosis

Lower limbs
- Necrobiosis lipoidica diabetica
- Skin atrophy
- Diabetic dermopathy
- Ulcers, infection
- Thighs: injection sites (lipohypertrophy), quads wasting (femoral mononeuritis)

Feet
- Hair loss, skin atrophy, blue/cold peropheries
- Ulcers
- Charcot joint
- Peripheral pulses, femoral bruits

Lower limb neuro
- Proximal power, reflexes
- Peripheral neuropathy

Upper limbs
- Nails: candida
- Upper arm injection sites

Eyes
- Visual acuity
- Argyll Robertson pupil
- Ophthalmoplegia (pupil may be spared in diabetic 3rd nerve palsy)

ENT
- Perinasal and periorbital swelling (mucor)
- Malignant otitis externa (pseudomonas)

Carotids
- Feel and auscultate for bruits

Abdomen
- Hepatomegaly

Other
- BP and pulse while lying and standing (postural)
- U/A: glucose, protein
- CKD signs
- Weight

10

What are the causes of hirsutism?

Cushing's syndrome
PCOS
Ovarian stromal tumour
CAH
Acromegaly
Porphyria cutanea tarda
Drugs: phanytoin, glucocorticoids