Important endocrine presentations

Question 1

Hypothyroidism: causes

Answer 1

Dietary iodine insufficiency.
Autoimmune thyroiditis (Hashimoto’s thyroiditis).
Lymphocytic thyroiditis (10% of post-partum women).
Drugs (amiodarone, interferon alpha, thalidomide, dopamine, lithium).
Radioactive iodine treatment.
Surgical thyroid injury.
External irradiation (e.g. for head and neck or breast cancer).
Pituitary adenoma.

Question 2

Hypothyroidism: symptoms

Answer 2

Tiredness
Weight gain
Anorexia
Cold intolerance
Poor memory
Depression
Reduced libido
Goitre
Puffy eyes
Brittle hair
Dry skin
Arthralgia
Myalgia
Muscle weakness
Constipation
Menorrhagia

Question 3

Hypothyroidism: signs

Answer 3

General: croaking voice, mental and physical sluggishness, pseudodementia, ‘myxoedema madness’.
Inspection: coarse, cool dry skin (look for yellowish tint of carotenaemia ‘peaches and cream’ complexion), palmar crease pallor, peripheral cyanosis, puffy lower eyelids, loss of outer 1/3 of eyebrows, thinning of scalp hair, tongue swelling, xanthelasma.
Cardiovascular and chest: mild HTN, pericarditis, pleural effusion, low cardiac output, cardiac failure, bradycardia, small volume pulse.
Neurological: carpal tunnel syndrome, peripheral neuropathy, cerebellar syndrome, proximal muscle weakness, myotonia, muscular hypertrophy, delayed ankle jerks, bilateral neural deafness.

Question 4

Hyperthyroidism: causes

Answer 4

Graves’ disease
Chronic thyroiditis (Hashimoto thyroiditis)
Subacute thyroiditis (de Quervain thyroiditis)
Postpartum thyroiditis
Drugs (iodine induced, amiodarone)
Bacterial thyroiditis
Postviral thyroiditis
Idiopathic
Toxic multinodular goitre
Malignancy (toxic adenoma, TSH-producing pituitary tumours)

Question 5

Hyperthyroidism: symptoms

Answer 5

Weight loss
Increased appetite
Irritability
Restlessness
Muscle weakness
Tremor
Breathlessness
Palpitations
Sweating
Heat intolerance
Itching
Thirst
Vomiting
Diarrhoea
Eye complaints (Graves' ophthalmopathy)
Oligomenorrhoea
Loss of libido
Gynaecomastia

Question 6

Hyperthyroidism: signs

Answer 6

General: irritability, weight loss.
Inspection: onycholysis, palmar erythema, tremor, sweaty palms, thyroid acropachy, hyperkinesis, gyanecomastia, pretibial myxoedema, Graves’ ophthalmopathy.
Cardiovascular and chest: resting tachycardia, high cardiac output, systolic flow murmurs.
Neurological: proximal myopathy, muscle wasting, hyperreflexia in legs.

Question 7

Glucocorticoid excess (Cushing’s syndrome): causes

Answer 7

High ACTH production from a pituitary adenoma and ectopic ACTH (e.g. small cell lung cancer).
Primary hypercortisolaemia caused by adrenal hyperplasia, adrenal tumour (adenoma or carcinoma), exogenous steroids.
Ectopic CRF production (v rare).
Depression.
Alcohol-induced.

Question 8

Glucocorticoid excess (Cushing’s syndrome): symptoms

Answer 8

Weight gain (central/upper body).
Change in appearance.
Menstrual disturbance.
Thin skin with easy bruising.
Acne.
Excessive hair growth.
Muscle weakness.
Decreased libido.
Depression. 
Insomnia.

Question 9

Glucocorticoid excess (Cushing’s syndrome): signs

Answer 9

Supraclavicular fat pads.
Moon face.
Thoracocervical fat pads (buffalo hump).
Centripetal obesity.
Hirsutism.
Thinning of the skin.
Easy bruising.
Purple striae.
Poor wound healing.
Skin infections.
Proximal muscle weakness (shoulders and hips).
Ankle oedema.
Hypertension.
Fractures due to osteoporosis.
Hyperpigmentation (if raised ACTH).
Glycosuria.

Question 10

Hypoadrenalism (Addison’s disease): causes

Answer 10

Autoimmune adrenalitis (>80% in UK).
TB.
Metastatic malignancy.
Amyloidosis.
Haemorrhage.
Infarction.
Bilateral adrenalectomy.
HIV.

Question 11

Hypoadrenalism (Addison’s disease): symptoms

Answer 11

Anorexia.
Weight loss.
Tiredness.
Nausea.
Vomiting.
Diarrhoea.
Constipation.
Abdominal pain.
Confusion.
Erectile dysfunction.
Amenorrhoea.
Dizziness.
Syncope.
Myalgia.
Arthralgia.

Question 12

Hypoadrenalism (Addison’s disease): signs

Answer 12

Skin pigmentation (especially on sun-exposed areas, mucosal surfaces, axillae, palmar creases, and in recent scars.
Cachexia.
Loss of body hair.
Postural hypotension.
Low-grade fever.
Dehydration.

Question 13

Growth hormone excess (acromegaly): causes

Answer 13

Pituitary tumour (>95%).
Hyperplasia due to GHRH excess (v rare).
Tumours in hypothalamus, adrenal, or pancreas.

Question 14

Growth hormone excess (acromegaly): symptoms

Answer 14

Headache.
Diplopia.
Change in appearance.
Enlarged extremities.
Deepening of voice.
Sweating.
Tiredness.
Weight gain.
Erectile dysfunction.
Dysmenorrhoea.
Galactorrhoea.
Snoring.
Arthralgia.
Weakness.
Numbness.
Paraesthesia.
Polyuria.
Polydipsia.

Question 15

Growth hormone excess (acromegaly): signs

Answer 15

Prominent supraorbital ridges.
Large nose and lips.
Prognathism (protrusion of lower jaw).
Interdental separation.
Macroglossia.
Spade-like hands.
Doughy soft tissues.
Thick oily skin.
Carpal tunnel syndrome.
Hirsutism.
Bitemporal hemianopia- if pituitary tumour impinging on optic chiasm.
Cranial nerve palsies (III, IV, and VI).
Hypertension.

Question 16

Prolactinoma

Answer 16

A pituitary tumour.

The most common hormone-secreting tumour.

Question 17

Prolactinoma: symptoms

Answer 17

Depend on age, sex, and degree of prolactinaemia.
In females: oligomenorrhoea, vaginal dryness, dyspareunia, galactorrhoea.
In males: loss of libido, erectile dysfunction, infertility, galactorrhoea; if before puberty may have female body habitus and small testicles.

Question 18

Prolactinoma: signs

Answer 18

Visual field defects (bitemporal hemianopia).
Cranial nerve palsies (III, IV and VI).
Galactorrhoea.
In males: small testicles and female pattern of hair growth.

Question 19

Hypercalcaemia: causes

Answer 19

Common: hyperparathyroidism, malignancy (PTHrP production or metastases in bone).
Less common: vitamin D intoxication, granulomatous disease, familial hypocalciuric hypercalcaemia.
Rare: drugs e.g. bendrofluazide, hyperthyroidism, Addison’s disease.

Question 20

Hypercalcaemia: symptoms

Answer 20

Depend largely on the underlying cause.
Mild hypercalcaemia is asymptomatic.
Higher levels may cause nausea, vomiting, drowsiness, confusion, abdominal pain, constipation, depression, muscle weakness, myalgia, polyuria, headache, and coma.

Question 21

Hypercalcaemia: signs

Answer 21

Often there are signs of the underlying cause.

There are no specific signs of hypercalcaemia.

Question 22

Hypocalcaemia: causes

Answer 22

Hypoalbuminaemia.
Hypomagnesaemia.
Hyperphosphataemia.
Surgery to the thyroid or parathyroid glands.
PTH deficiency or resistance.
Vitamin D deficiency.

Question 23

Hypocalcaemia: symptoms

Answer 23

Depression.
Paraesthesia around the mouth.
Muscle spasms.

Question 24

Hypocalcaemia: signs

Answer 24

Trousseau’s sign.

Chvostek’s sign.

Question 25

Polycystic ovarian syndrome (PCOS)

Answer 25

Abnormal metabolism of androgens and oestrogen with abnormal control of androgen production.

Question 26

Polycystic ovarian syndrome (PCOS): symptoms

Answer 26

Oligomenorrhoea with anovulation and erratic periods.
Infertility.
Hirsutism.

Question 27

Polycystic ovarian syndrome (PCOS): signs

Answer 27

Obesity (50%).
Male-pattern hair growth.
Male-pattern baldness.
Increase muscle mass.
Deep voice.
Clitoromegaly.
Acanthosis nigricans.