Symptoms in endocrinology

Question 1

Symptoms to ask about in endocrinology

Answer 1

Appetite and weight changes.
Lethargy.
Bowel habit.
Urinary frequency and polyuria.
Thirst and polydipsia.
Sweating.
Pigmentation.
Hair distribution- loss or gain.
Skin and soft tissue changes.
Headache and visual disturbance.
Alteration in growth.
Change in sexual function.
Flushing.

Question 2

Endocrinology history: appetite and weight changes

Answer 2

Many people do not weight themselves but may have noticed the consequences of weight change such as clothes becoming looser or tighter.

Question 3

Endocrinology history: lethargy

Answer 3

Lethargy or fatigue is a difficult symptom to pin down.
Ask the patient how the tiredness impacts on their daily life.
What are they able to do before needing to rest, and has this changed?
Fatigue may be a feature of undiagnosed endocrine disease, such as diabetes mellitus, Cushing’s syndrome, hypoadrenalism, hypothyroidism, hypercalcaemia.
Consider depression and chronic disease of any other kind (anaemia, chronic liver and renal problems, chronic infection, and malignancy).

Question 4

Endocrinology history: bowel habit

Answer 4

Constipation is a common feature of hypercalcaemia and hypothyroidism.
Hyperthyroidism and Addison’s disease may give diarrhoea.

Question 5

Endocrinology history: urinary frequency and polyuria

Answer 5

Diabetes mellitus.
Diabetes insipidus.
Hyperglycaemia caused by Cushing’s syndrome.
Polyuria may also be seen in the presence of hypercalcaemia.

Question 6

Endocrinology history: thirst and polydipsia

Answer 6

Consider diabetes mellitus, diabetes insipidus, and hypercalcaemia.

Question 7

Endocrinology history: sweating

Answer 7

Increased perspiration may be seen during episodes of hypoglycaemia as well as in hyperthyroidism and acromegaly, and is associated with the other adrenergic symptoms of phaeochromocytoma.

Question 8

Endocrinology history: pigmentation

Answer 8

Localised loss of pigmentation may be due to vitiligo- an autoimmune disorder associated with other endocrine immune disease, such as hypo- or hyperthyroidism, Addison’s disease, and Hashimoto’s thyroiditis.
Increased pigmentation = Addison’s disease, Cushing’s syndrome.
Decreased pigmentation = generalised loss of pigmentation in hypopituitarism.

Question 9

Endocrinology history: hair loss

Answer 9

Decreased adrenal androgen production and loss of axillary and pubic hair in both sexes can be caused by hypogonadism, adrenal insufficiency.

Question 10

Endocrinology history: hair gain

Answer 10

Hirsutism or excessive hair growth in a female may be due to endocrine dysfunction.
Polycystic ovarian syndrome.
Cushing's syndrome.
Congenital adrenal hyperplasia.
Acromegaly.
Virilising tumours.

Question 11

Endocrinology history: skin and soft tissue changes, hypothyroidism

Answer 11

Dry, coarse, pale skin with xanthelasma formation and, classically, loss of the outer 1/3 of the eyebrows.

Question 12

Endocrinology history: skin and soft tissue changes, hyperthyroidism

Answer 12

Thyroid acropachy is seen only in hyperthyroidism due to Graves’ disease.
Features include finger clubbing and new bone formation at the fingers.
Also pretibial myxoedema- reddened oedematous lesions on the shins, often lateral aspects.

Question 13

Endocrinology history: skin and soft tissue changes, hypoparathyroidism

Answer 13

Generally dry, scaly skin.

Question 14

Endocrinology history: skin and soft tissue changes, diabetes mellitus

Answer 14

Xanthelasma, ulceration, repeated skin infections, necrobiosis lipoidica diabeticorum- shiny, yellowed lesions on the shins.

Question 15

Endocrinology history: skin and soft tissue changes, acromegaly

Answer 15

Soft tissue overgrowth with skin tags at the axillae and anus, ‘doughy’ hands and fingers, acanthosis nigricans- velvety black skin changes at the axilla.

Question 16

Endocrinology history: headache and visual disturbance

Answer 16

Visual field defects, cranial nerve palsies, and headache may be caused by space-occupying lesions within the skull.
Pituitary tumours classically cause a bitemporal hemianopia by impinging on the optic chiasm.
Blurred vision is rather non-specific, but consider osmotic changes in the lens due to hyperglycaemia.

Question 17

Endocrinology history: alteration in growth

Answer 17

Hypopituitarism, hypothyroidism, growth hormone deficiency, and steroid excess may present with short stature.
Tall stature may be caused by growth hormone excess or gonadotrophin deficiency.
Growth hormone excess in adults (acromegaly) causes soft tissue overgrowth. Patients notice an increase in shoe size, glove size, or facial appearance- old photographs for comparison?

Question 18

Endocrinology history: changes in sexual function

Answer 18

Women: altered menstrual pattern in a female may be an early symptom suggestive of pituitary dysfunction.
Men: hypogonadism may result in loss of libido and an inability to attain or sustain an erection.

Question 19

Endocrinology history: flushing

Answer 19

Flushing may be a symptom of carcinoid or the menopause.
Ask about the nature of the flushing, any aggravating or relieving factors, and any other symptoms at the time such as palpitations, diarrhoea, dizziness.
Take a full menstrual history.

Question 20

Endocrinology history: drug history

Answer 20

Over the counter medicines.
Hormonal treatments- include oral contraceptive pill, local and systemic steroids.
Amiodarone.
Lithium.
Herbal or other remedies.

Question 21

Endocrinology history: past medical history

Answer 21

Any previous thyroid or parathyroid surgery.
Any previous 131I (radio-iodine) treatment or antithyroid drugs.
Gestational diabetes.
Hypertension.
Any previous pituitary or adrenal surgery.

Question 22

Endocrinology history: family history

Answer 22

Type II diabetes.
Related autoimmune disorders (pernicious anaemia, coeliac disease, vitiligo, Addison’s disease, thyroid disease, type I diabetes).
Congenital adrenal hyperplasia.
Tumours of the MEN syndromes.

Question 23

General endocrine examination: hands/arms

Answer 23

Look at size, subcutaneous tissue, length of the metacarpals, nails, palmar erythema, sweating and tremor.
Note skin thickness (thin in Cushing’s, thick in acromegaly) and look for signs of easy bruising.
Pulse and blood pressure- lying and standing.
Test for proximal muscle weakness.

Question 24

General endocrine examination: axillae

Answer 24

Note any skin tags, hair loss, abnormal pigmentation, or acanthosis nigricans.

Question 25

General endocrine examination: face and mouth

Answer 25

Look for hirsutism, acne, plethora, or skin greasiness.
Look at the soft tissues of the face for prominent glabellas (above the eyes) and enlargement of the chin (macrognathism).
In the mouth, look at the spacing of the teeth and if any have fallen out.
Note any buccal pigmentation and macroglossia.
Note any prognathism (upper teeth closing behind instead of in front of lower teeth).

Question 26

General endocrine examination: neck

Answer 26

Note any swellings or lymphadenopathy.
Examine the thyroid.
Palpate the supraclavicular regions and note excessive soft tissue.

Question 27

General endocrine examination: chest

Answer 27

Inspect for any hair excess or loss, breast size in females and gynaecomastia in males.
Note the nipple colour, pigmentation, or galactorrhoea.

Question 28

General endocrine examination: abdomen

Answer 28

Inspect for central adiposity/obesity, purple striae, hirsutism.
Palpate for organomegaly.
Look at the external genitalia to exclude any testicular atrophy in males or virilisation (e.g. clitoromegaly) in females.

Question 29

General endocrine examination: legs

Answer 29

Test for proximal muscle weakness and make note of any diabetes-related changes.

Question 30

General endocrine examination: height and weight

Answer 30

Calculate patient’s BMI.

Question 31

General endocrine examination: signs of tetany

Answer 31

Trousseau’s sign: inflate a BP cuff just above systolic pressure for 3 minutes. When hypocalcaemia has caused muscular irritability, the hand will develop flexor spasm.
Chvostek’s sign: gently tap over the facial nerve in front of the tragus of the ear. The sign is positive if there is contraction of the lip and facial muscles on the same side of the face.