clinical examination

1. CLINICAL EXAMINATION OF
ENDOCRINE SYSTEM

2.  Diabetis mellitus
 Osmotic symptoms
 Hyperglycemia-renal threshold-glycosuria
 despite hyperglycaemia,people with an increased renal
threshold for glucose may have no osmotic symptoms
 D/D
 Diabetis Inspidus
 Central
 Nephrogenic
▪ Inherited
▪ impairment of antidiuretic hormone
action by hypercalcaemia or hypokalaemia
 Psychogenic polydipsia

3.  Hyperthyroidism
 Type 1 insulin-dependent diabetes mellitus
 Hypopituitarism
 Adrenocortical failure (Addison’s disease)
 Anorexia nervosa

4.  Simple obesity: energy intake/expenditure
imbalance
 Primary hypothyroidism
 Cushing’s syndrome
 Hypothalamic lesions
 Leptin defciency

5.  Symmetrical proximal weakness, mainly involving the
shoulder and hip girdle musculature.There is usually
associated muscle wasting
 diffculty in climbing stairs, boarding a bus or rising from a
sitting/squating position
 Painless
 Hyperthyroidism
 Cushing’s syndrome, including iatrogenic steroid myopathy
 Acromegaly
 Painful
 Vitamin D defciency
 Osteomalacia
 Hypothyroidism

6.  Cold intolerance
 hypothyroidism
 Heat Intolerance
 hyperthyroidism

7.  constitutional abnormality
 Anxiety
 Hyperthyroidism
 Phaeochromocytoma
 acromegaly

8.  fine rapid resting tremor- thyrotoxicosis
 D/D
 Tremor frequency:
 low frequency < 4 Hz (cerebellar tremor)
 medium frequency, 4-7 Hz (parkinsonian tremor,
physiological tremor, essential tremor,dystonic
tremor,drug-induced tremor, psychogenic tremor)
 high frequency > 7 Hz (essential tremor,
physiological tremor)

9.  Palpitations are a heightened, unpleasant
awareness of the heart beat.
 Thyrotoxicosis
 D/D
 paroxysmal tachyarrhythmias

10.  Dizziness, or a sensation of faintness on
standing
 Postural hypotension – SBP fall >20 mmhg,
DBP fall > 10 mmhg within 3 minutes
 Adrenal insufficiency (exclude Bleeding/GI blood
loss)
 Autonomic neuropathy (Diabetis)
 Drug therapy for essential hypertension

11.  Decreased visual acuity- spaceoccupying lesions
compressing the optic nerve
 severe dysthyroid eye disease and orbital
or retro-orbital tumours
 Bitemporal hemianopia
 Suprasellar extension of pituitary adenomas compressing
the optic chiasm
 Double vision (diplopia) on lateral or upward gaze
 Medial,lateral, inferior rectus muscle tethering in
dysthyroid eye disease.
 Apparent magnifcation of vision (macropsia)
 hypoglycaemia

12.  Tachycardia, sweating and tremor -
hypoglycaemia.
 Decreased consiousness
 Autonomous insulin production - insulinoma.
 Glucocorticoid defciency, with or without
thyroxine and growth hormone defciency
(e.g.primary adrenal failure or hypopituitarism)
 Inappropriate insulin or excessive sulphonylurea
drug administration in a diabetic patient
 hepatic failure

13.  decreased level of circulating ionized calcium
 Hypoparathyroidism
 fall in the ionized component of serum
calcium, owing to an increased extracellular pH
(alkalosis)
▪ respiratory alkalosis - hyperventilatory states
▪ metabolic alkalosis - hypokalaemia
 Hypomagnesaemia

14.  adrenal insuffciency
 hypercalcaemia
 D/D
 Exclude GI causes

15.  multinodular thyroid enlargement with
retrosternal extension

16.  viral subacute thyroiditis (de Quervain’s
thyroiditis)
 autoimmune thyroiditis
 bleeding into a pre-existing thyroid nodule
 Painless enlargement of the thyroid gland (goitre)
presents either with pressure effects- dysphagia,
tracheal compression and stridor, or cosmetic
disturbance

17.  Reduced erectile potency
 Decreased blood supply to the penis (e.g.
atherosclerosis).
 Neural dysfunction (e.g. autonomic neuropathy
complicating diabetes)
 Testosterone defciency (e.g. hypopituitarism
and primary testicular failure)
 Hyperprolactinaemia
 Drug therapy (e.g. certain antihypertensives (diuretics, beta
blockers, central acting – methyl dopa)
 Psychological factors
 total erectile failure and the absence of nocturnal and morning
erections suggest a physical cause

18.  “Gynaecomastia” means “woman’s breast” refers to a smooth, firm, mobile,
often tender disc of breast tissue under the areola in the male
Increased oestrogen/testosterone ratio
 Chronic liver disease
 Thyrotoxicosis
 Phenytoin therapy
 Androgen receptor antagonists
 Spironolactone, digoxin
 Inherited androgen receptor defects
 Testicular feminization syndrome
 Testosterone defciency or oestrogen excess
 Primary and secondary hypogonadism
 Tumour production of human chorionic gonadotrophin
(hCG)
 Oestrogen production by Leydig cell tumour of testis
 Congenital and hereditary
 X-linked spinal muscular atrophy (Kennedy syndrome)
 Klinefelter’s syndrome (karyotype XXY)

19.  primary amenorrhoea - failure of onset of
menses
 hypothalamic–pituitary dysfunction (e.g. due
to tumours)
 ovarian failure (e.g. failure of normal ovarian
development or cytotoxic chemotherapy)
 thyroid dysfunction
 defects in lower genital tract development.
 Secondary amenorrhoea (cessation of previously
established menses

20.  Idiopathic galactorrhoea, in which there is an
apparent increased sensitivity to normal levels
of serum prolactin.
 Prolactin-secreting tumours of the pituitary
gland.
 Hyperprolactinaemia due to hypothyroidism.
 Hyperprolactinaemia due to dopamine
antagonist drugs.(typical antipsychotics)
 Hyperprolactinaemia due to lactotroph
disinhibiting lesions of the hypothalamopituitary
region.

21.  Sexual hair – face, Axilla, Pubis
 growth of facial and body hair in adult females -
increased circulating androgens.
Normal
 Pathological causes of hirsutism
include:
 polycystic ovary syndrome
 late presentation of congenital adrenalhyperplasia
 androgen-secreting ovarian or adrenal tumours

22.  Constipation and abdominal distension -
hypothyroidism or panhypopituitarism.
 Diarrhoea – autonomic neuropathy involving
the gut in diabetes mellitus.
 Peptic ulceration
 Zollinger–Ellison syndrome

23.  Pigmentation
 Acne
 Pretibial myxedema

25.  measure weight and height
 Calculate BMI
 Distribution of fat
 cushing syndrome
 Buccal fat pads

26.  increased fullness and
coarsening of soft
tissues,including the lips and
tongue overgrowth of the
zygoma, orbital ridges and
mandible (prognathism)
 Acromegaly in young
people occurring
before epiphyseal
fusion causes
abnormally tall stature
gigantism

27.  skeletal proportions should be noted
 Lower segment > Upper segment
& Arm span> height – delayed epiphyseal
fusion
 Eunuchoidism
 Marfan syndrome

28.  short stature
 failure of secondary sexual
development
 decreased or absent
secondary sexual hair
 an increase in the normal
angulation between
the humerus and the
lower arm
 a low posterior hairline
and an exaggerated fold
of skin between the neck
and shoulder

29.  Excessive pigmentation occurs in
adrenocorticotrophic hormone (ACTH)-
dependentCushing’s syndrome

30.  Increased sebum
production causing
greasy skin and acne
on the face and
shoulders may
occur in all causes
of glucocorticoid excess

31.  hypothyroidism, the skin appears dry, pale,
sallow or even slightly yellow, scalp hair is
coarse and lateral eyebrow hair is thinned

32.  patchy
depigmentation
of the skin
autoimmune
disorders,
autoimmune
hypothyroidism
& vitamin B12
defciency.

33.  skin, mostly in the
axillae and nape of
the neck becomes
dark, soft, and
velvet-like with
delicate fold
 acromegaly
 hyperprolactinemia
 diabetes mellitus
 Cushing’s syndrome
 excessive androgen
production

34.  anterior tibia and dorsum
of the feet and toes,
consisting of nonpitting,
thickenning and induration
of the skin
 Glycosaminoglycans
deposition in the reticular
dermis

35.  excess hair growth in
an androgen-
dependent
distribution
(hirsutism)
 hair loss in a male
pattern
 indicate increased
circulating androgen
 examination for
evidence of
virilization

36.  Inspection
 Palpation
 Diffuse enlargement
 Multinodular goitre
 Single nodule
 consistency

37.  Pubertal development
10 and 11 and takes 3
to 4 years to
complete.
 growth spurt starts
about 1 year before
breast development,
peak height velocity is
reached on average 1
year later, and
menarche follows in
an average of 1 year.

38.  In males, pubertal
development usually
commences between the
ages of 11 and 12, takes
approximately 3 years to
complete
 testicular development,
beginning of pubic hair,
beginning of growth
spurt and peak height
velocity

39.  Genital examination in the male should document
testicular volume
 Prepubertal testicular volume is less than 4 ml
 pubertal growth spurt in boys is associated with a
testicular volume of 10 ml
 normal adult testicular volume is in the range
of 15 to 25 ml
 Testicular atrophy in the adult male indicates
hypogonadism, due either to primary testicular
failure, hypothalamopituitary dysfunction or chronic
liver disease

40.  Visual aquity
 visual fields
 Fundus examination

41.  corneal calcifcation – hypercalcemia

42.  exophthalmos (proptosis)
 Lid retraction
 Lid lag

43.  Fine tremor – thyrotoxicosis
 Proximal muscle weakness - thyrotoxicosis,
glucocorticoid excess and vitamin D defciency
 Hypocalcaemia – neural excitability -Chvostek’s sign
 Tendon reflexes
 abnormally brisk - thyrotoxic patients
 slow relaxation – hypothyroidism
 nerve entrapment syndromes - median nerve at the
wrist (carpal tunnel syndrome)
 Hypothyroidism
 acromegaly