Endocrinology Flashcards
Go through the approach to examination of acromegaly
Hands
- spade-like, sweating, warm
- Phalen’s for CTS (+ probably test sensation and opposition quickly)
OA
- hands, shoulders, hips, knees
Fundoscopy
- optic atrophy, papilloedema, angioid streaks
- diabetic or hypertensive changes
Pituitary
- signs of hypogonadism (from pituitary tumour)
- signs of hypothyroidism or adrenocortical insufficiency
Other
- photographs or rings over the years for inspection
Go through the approach to examination of cushing’s syndrome
Don’t forget to mention looking at the genitalia
- virilisation in women or gynaecomastia in men may suggest adrenal carcinoma
Go through the approach to examination of the diabetic patient
- *Legs**
- wasting of quad (amyotrophy = femoral nerve mononeuritis)
- muscle power, reflexes, dorsal columns
- *Arms**
- ask for BP + posturals!
- pulse lying and standing for autonomic neuropathy
- *Eyes**
- diabetic 3rd nerve often spares the pupil (affects the inner > outer fibres)
- *Mouth and Ears**
- candida
- mucormycosis if periorbital/nasal swelling
- ears for malignant otitis externa from pseudomonas
- *Other**
- weight
Go through the neck (thyroid) examination
Palpate
- one hand steadies the gland, the other hand feels
- single vs multinodular if a nodule is felt
- note hoarseness, note tenderness
- if you can’t get below the gland think retrosternal goitre
Hyperthyroid suspected
- thyroid bruit; systolic flow murmur over carotids; goitre; thyroid eye disease
- eyes: look for exophthalmos, lid retraction, lig lag, injected conjunctiva
- eyes: look for ophthalmoplegia (inferior oblique -> convergence -> others)
- eyes: look for optic atrophy
- hands: look for tremor (paper), onycholysis, thyroid acropachy (clubbing), palmar erythema
- hands: look for warmth, sweating
- pulse: radial pulse for sinus tachycardia, AF, or collapsing pulse
- arms: proximal myopathy or brisk reflexes
- legs: pretibial myxoedema, vitiligo, proximal myopathy, hyperreflexia
- chest: gynaecomastia, ES murmur, CCF
- abdomen: mild hepatosplenomegaly
- generalised lymphadenopathy
Thyroidectomy scar
- hypocalcaemia: Chovstek’s and Trousseau’s
Hypothyroid suspected
- hands: cyanosis, swelling, dry/cold skin; anaemia; CTS (Phalen’s)
- pulse: bradycardia and small volume
- arms: delayed relaxation of biceps jerk; proximal myopathy (rare)
- face: general swelling, periorbital oedema, outer third eyebrows lost, xanthelasma
- face: carotenaemia, alopecia, vitiligo; swollen tongue
- speech: hoarseness, slowness
- hearing: neurological deafness
- legs: slow relaxation of ankle jerks (kneeling on a chair best), peripheral neuropathy
- chest: pleural or pericardial effusions; dry, rough, sandpaper like skin
What are the causes of a diffuse goitre?
What are the causes of anaemia in those with hypothyroidism?
What are the causes of angioid streaks on the retina?
Paget’s, pseudoxanthoma elasticum, poisoning (lead)
Acromegaly
Sickle cell anaemia
Hhyperphosphataemia (familial)
What are the causes of hirsutism?
- Constitutional (normal endocrinology)
- PCOS
- Adrenal
- cushing’s
- CAH (21 or 11 hydroxylase deficiency)
- virilising adrenal tumour
- Ovarian
- stromal ovarian cancer
- Drugs
- phenytoin, diazoxide, streptomycin, minoxidil, androgen, glucocorticoids
- Other
- acromegaly, PCT
What are the causes of hypothyroidism
- *PRIMARY**
- Without** a goitre (decreased or absent thyroid tissue*)
- Idiopathic atrophy
- Treatment (e.g. iodine-131, surgery)
- Agenesis, lingual thyroid
- Unresponsiveness to TSH
With a goitre (decreased synthesis)
- Chronic thyroiditis: late Hashimoto’s, Riedel’s thyroiditis
- Drugs: lithium, amiodarone
- Endemic iodine deficiency
- Iodine-induced hypothyroidism
- Inborn errors (enzyme deficiency)
SECONDARY
- Pituitary lesions
TERTIARY
- Hypothalamic lesions
TRANSIENT
- Thyroid hormone treatment withdrawl
- Subacute thyroiditis
- Postpartum thyroiditis
What are the causes of panhypopituitarism and the order of loss of function?
What are the causes of Thyrotoxicosis (hyperthyroidism)?
Primary:
- Graves’ Disease
- Toxic adenoma, MNG
- Thyroiditis: Hashimotos, subacute
- Iodine induced (after previous iodine deficiency)
- Excess thyroid hormone replacement
- Postpartum thyroiditis (non tender)
- Drugs: amiodarone, lithium
Secondary:
- Pituitary or ectopic TSH hypersecrection
- Hydatidiform mole or choriocarcinoma (HCG secretion - rare)
- Struma ovarii
- Factitious
What are the features of activity in acromegaly?
- Skin tag number
- Excessive sweating
- Glycosuria
- Increasing visual field loss
- or III, IV, VI, V palsies
- Enlarging goitre
- Hypertension
- Symptoms
- headache, increasing ring/shoe/denture size
What are the features of panhypopituitarism?
Short stature, reduced body hair, increased abdominal fat
- short if failed GH secretion before growth complete
Partial breast development (from oestrogen replacement)
- may have no secondary sexual characteristics if gonadotrophin failure before puberty
Absence of axillary/pubic hair (failure of adrenal androgen production)
- look for testicular atrophy in men
Face
- multiple, fine skin wrinkles around the eyes and mouth are characteristic of GH deficiency
- hypophysectomy scar on forehead near the inner canthus
Eyes
- pituitary tumour: bitemporal hemianopia, optic atrophy; 3/4/V1/6 (tumour extension into cavernous sinus)
Other
- ankle jerks for slow relaxation of hypothyroidism
- BP with postural for ACTH deficiency
What are the primary and secondary causes of addison’s disease?
Iatrogenic
Primary
- Autoimmune in >80%
- polyglandular syndrome I: APECED (addison’s, hypoparathyroid, mucocutaneous candidiasis, primary hypogonadism)
- polyglandular syndrome II: addison’s, T1DM, hashimoto’s or graves’, primary hypogonadism
- infection: waterhouse-friderichsen syndrome (neisseria, TB), histoplasmosis
- infiltration: amyloid, sarcoid, malignant disease
- demyelination: adrenoleukodystrophy (addison’s + asymmetrical cortical signs), adrenomyeloneuropathy (addison’s + spastic paraparesis)
- drugs: heparin, ketoconazole
Secondary (usually no mineralocorticoid deficiency)
- pituitary
- hypothalamic
What do you look for in suspected hypothyroidism?
Hypothyroid suspected
- hands: cyanosis, swelling, dry/cold skin; anaemia; CTS (Phalen’s)
- pulse: bradycardia and small volume
- arms: delayed relaxation of biceps jerk; proximal myopathy (rare)
- face: general swelling, periorbital oedema, outer third eyebrows lost, xanthelasma
- face: carotenaemia, alopecia, vitiligo; swollen tongue
- speech: hoarseness, slowness
- hearing: neurological deafness
- legs: slow relaxation of ankle jerks (kneeling on a chair best), peripheral neuropathy
- chest: pleural or pericardial effusions; dry, rough, sandpaper like skin
What are the common and rare neurological associations of hypothyroidism?
