Endocrine Flashcards
Causes of neck swelling
MIDLINE: goitre (moves on swallow), thyroglossal cyst (moves on poking the tongue), submental lymph nodes, parathyroid gland.
LATERAL: lymph nodes, salivary glands (e.g. stone, tumour), sebaceous cyst or lipoma, cystic hygoma, aneurysm or tumour, pharyngeal pouch or brachial remnant.
Causes of a diffuse goitre
- Idiopathic
- Puberty or pregnancy
- Thyroiditis (if subacute usually tender)
- Simple goitre due to iodine deficiency
- Inborn errors of thyroid hormone synthesis
Causes of a solitary thyroid nodule
BENIGN: dominant nodule in MNG, degeneration or haemorrhage into a colloid cyst, follicular adenoma, simple cyst (rare).
MALIGNANT: carcinoma (primary or secondary), lymphoma (rare)
Causes of exopthalmos
BILATERAL: grave’s disease
UNILATERAL: tumours of the orbit, cavernous sinus thrombosis, grave’s disease, psuedotumours of the orbit.
Hypothyroidism: CFx
GENERAL: mental and physical sluggishness.
HANDS: peripheral cyanosis (reduced CO), cool and dry skin, yellow discolouration of palms due to hypercarotenaemia (slowed hepatic metabolism), palmar crease pallor (anaemia)
ARMS: proximal myopathy (rare), hung up biceps reflex (delayed relaxation)
FACE: thickened skin, alopecia, vitiligo (an assoc autoimmune disease), periorbital oedema, loss or thinning of outer third of the eyebrows, coolness of skin and hair
THYROID: may see goitre (due to oversecretion of TSH) if cause severe iodine deficiency, late Hashimoto’s disease, treated thyrotoxicosis, inborn errors of metabolism.
CHEST: pericardial effusion, pleural effusion
LEGS: non-pitting oedemea, delayed relaxation of LL reflexes (‘hung up’), peripheral neuropathy
Neuro associations: entrapment of nerves, delayed ankle jerk, muscle cramps. Less common: peripheral neuropathy, proximal myopathy, hypokalaemic periodic paralysis
Hyperthyroidism: CFx
GENERAL: weight loss, anxiety
HANDS: fine tremor (sympathetic overactivity), onycholysis, thyroid acropathy (clubbing), palmar erythema, sweatiness/warmth
PULSE: sinus tachycardia or AF (shortened refractory period to do sympathetic drive)
ARMS: proximal myopathy, brisk reflexes
EYES: exophthalmos, proptosis (Cx= chemosis [oedema of conjunctiva and injection of sclera], corneal ulceration, optic atrophy, opthalmoplegia [infeior rectus lost first]), lid retraction, test for lid lag (descent of lid lags behind eyeball)
NECK: examine for thyroid enlargement (Graves = diffuse enlargement, subacute = tender thyroid). If thryoidectomy scar assess for hypoparathyroidism
CHEST: systolic flow murmurs, CCF
LEGS: pretibial myxodema (Graves), proximal myopathy and hyperreflexia
Causes of thyrotoxicosis
PRIMARY: Grave’s disease, toxic multinodular goitre, hashimoto’s thyroiditis in early stage, subacute thyroditis, post partum thyriditis, iodine induced
SECONDARY: pituitary (rare), hydatidorm moles or choriocarcinomas, struma ovarii, drugs (amiodarone)
Causes of hypothyroidism
PRIMARY:
- Without goitre (decreased or absent thyroid tissue): idiopathic atrophy, treatment of thyrotoxicosis, agenesis or a lingual thyroid, unresponsiveness to TSH.
- With a goitre (decreased thyroid hormone synthesis): chronic autoimmune disease (e.g. Hashimoto’s), drugs (lithium, amiodarone), inborn errors, endemic iodine deficiency
SECONDARY: pituitary lesions
TERTIARY: hypothalamic lesions
TRANSIENT: thyroid hormone withdrawn, subacute thyroiditis, post partum thyroiditis.
Panhypopituitarism: CFx
GENERAL: short stature (failure of growth hormone secretion pre pueberty), pallor (anaemia or ACTH deficiency), fine-wrinkled skin and lack of body hair (gonadotrophin deficiency).
FACE: skin wrinkles around eyes, scars (can’t see transsphenoidal ones)
EYES: visual fields for bi-temporal hemianopia, fundi exam for optic atrophy (optic nerve compression from a pituitary tumour), assess CN 3, 4, 6 and 1st division of 5 as may be affected by tumour expansio into the cavernous sinus, decreased beard growth in gonadotrophin deficiency
CHEST: skin pallor, decreased nipple pigmentation, decreased body hair, women breast atrophy
GENITAL: loss of pubic hair, testicular atrophy
LEGS: ‘hung up’ ankle jerk
Acromegaly: CFx
GENERAL: characteristic face and body habitus with frontal bossing
HANDS: spade-like hands (due to soft tissue and bony enlargement), increased sweating and warmth (increased metabolic rate), thickened skin, OA changes due to skeletal overgrowth, examine for median nerve entrapment (due to soft tissue overgrowth)
ARMS: proximal myopathy, ulnar nerve thickening behind medial epicondyle
BP check
AXILLAE: skin tags (molluscum fibrosum), feel for greasy skin, acanthosis nigricans
FACE: supraorbital ridge causing frontal bossing, thickened lips
EYES: examine visual fields for bitemporal hemianopia, look in fundi for optic atrophy, angioid streaks (red brown streaks that emanate from the optic disk), diabetic changes and papilloedema,
MOUTH: enlarged tongue, teeth splayed and separated
NECK: enlarged thyroid
CHEST: coarse body hair, gynaecomastica, arrhythmias, cardiomegally, CCF
BACK: kyphosis
ABDO: hepatic, splenic and renal enlargment, look for tesitcular atrophy.
LL: OA in hips and knees. Foot drop due to common peroneal nerve entrapment
Ask for:
- urine ?glucose
- rectal exam ?colonic polyps
Signs of active disease: large number of skin tags, excessive sweating, glycosuira, increased visual field loss, enlarging goitre, hypertension.
Cushing syndrome: CFx
GENERAL: moon-like facies, central obesity, bruising (loss of perivascular supporting tissue protein catabolism), excessive pigmentation (melanocyte like activity in ACTH molecule).
HANDS: skin fold thickness (N=>1.8mm)
BP
FACE: plethora, moon shape, acne, hirsutism. telangiectasia.
EYES: visual fields (pituitary tumour), fundi (optic atrophy, hypertensive/diabetic changes, papilloedema)
ABDO: striae (weakening collagen fibres), palpate for adrenal masses, hepatomegally (fat deposition, adrenal carcinoma deposits)
BACK: buffalo hump, palpate for vertebral tenderness
LEGS: proximal myopathy, oedema, bruising, poor wound healing
Urine: sugar
Cushings syndrome: specific aeitology with signs
Underlying adrenal carcinoma: palpable abdominal mass, signs of virilisation, gynacomastia (male)
Underlying ectopic ATCH production: absence of cushingoid body habitus, more prominent oedema and hypertenison, marked muscle weakness
Hyperpigmentation: suggests an extra-adrenal tumour or enlargment of an ACTH secreting pituitary adenoma following adrenalectomy
Addison’s disease: CFx
GENERAL: cachexia
HANDS: pigmentation in the palmar creases, elbows
FACE: pigmentation in gums and buccal areas, vitiligo (assoc condition)
BP and assess for postural hypotension
Pigmentation due to ACTH compensatory increased secretion
Causes of gyaecomastica
INCREASED OESTROGEN PRODUCTION: leydig cell tumour, adrenal carcinoma, bronchial carcinoma (human chorionic gonadotrophin), liver disease (increased conversion of oestrogen from androgens), thyrotoxicosis (increased conversion O from A), starvation
DECREASED ANDROGEN PRODUCTION: klinefelter’s syndrome, secondary testicular failure (orchitis, castration)
DRUGS: oestrogen receptor binders (ostrogen, digoxin, marijuana), anti-androgens (spironolactone, cimetidine)
Diabetes: CFx
GENERAL: dehydration, obesity, cushing’s faecies, kussmaul’s breathing
LOWER LIMBS:
- Inspect: necrobiosis, hair loss, pigmented scars, ulceration, superficial skin infection, diabetic dermopathy (small rounded plaques with raised borders lying in a linear fashion over the shins), injection sites on thighs, charcot’s joints (grossly deformed joints due to loss of proprioception or pain)
- Palpate: peripheral pulses, capillary return
- Neuro ex: peripheral neuropathy, proprioception, reflexes, proximal myopathy
UPPER LIMBS:
- Nails: ?candida
BP including postural drop
FACE:
- Eyes: visual acuity, look for argyll robertson pupils, examine retina, assess for opthalmoplegia (CN III palsy most common)
- Ears: examine for signs of infection
- Mouth: ?candida
NECK:
Carotid arteries palpate and ascultate
CHEST: look for acanthosis nigricans
ABDO: palpate for hepatomegally
ASK:
- Urinanalysis ?glucose, ?proteinuria
