Endocrinology

Question 1

What are the components of the neck exam?

Answer 1

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

Question 2

What are the DDx for gynaecomastia?

Answer 2

• 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

Question 3

Acromegaly:

• Ix
• Mx
• Cx

Answer 3

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

Question 4

What are the clinical signs of acromegaly?

Answer 4

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)

Question 5

What are the components of the hypopituitarism examination?

Answer 5

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

Question 6

What are the components of the Cushing’s exam?

Answer 6

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)

Question 7

What are the signs of disease activity in acromegaly?

Answer 7

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

Question 8

What are the components of the Addison’s examination?

Answer 8

Observation

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

BP
- Postural drop

Question 9

What are the components of the diabetic examination?

Answer 9

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

Question 10

What are the causes of hirsutism?

Answer 10

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