Endocrine System Examination Notes For Medical Students

Table of Contents

ENDOCRINE SYSTEM EXAMINATION

Introduction, Wash Hands, Consent,
General Inspection:
- Facies:
  - Moon Facies (Cushings)

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- - Frightened Stare (Graves – Hyperthyroidism)

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- - Anhedonic + Puffy Eyes (Hashimotos – Hypothyroidism)
  - Frontal Bossing, Enlarged Jaw/Tongue/Nose/Ear/Brow (Acromegaly)

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- - Hyperpigmented + Wasting (Addison’s)

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- - Hirsutism + Receding Hairline (PCOS)

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- Body Habitus:
  - Obesity (D2M, Cushing’s, Hypothyroidism)
  - Wasting (D1M, Addison’s, Hyperthyroidism)
  - Central Adiposity (Cushing’s Syndrome)
- Hair Distribution:
  - Hair Loss (Hypothyroidism)
  - Hirsutism (Cushing’s & PCOS)
- Pigmentation:
  - Generalised Hyperpigmentation (Addisons, Haemochromatosis)
  - Acanthosis Nigricans (Diabetes, Cushing’s, Acromegaly, PCOS)
- Mental Changes:
  - Slowness (Hypothyroidism, DKA, HONC, Addison’s)
  - ↓Affect (Hypothyroidism)
Vital Signs:
- Pulse:
  - Tachycardia (Hyperthyroidism, Phaeochromocytoma, DKA)
  - Bradycardia (Hypotension)
- Blood Pressure:
  - Hypertension (Hyper & Hypothyroidism/Phaeo/Cushing’s/Conn’s/PCOS/Acromegaly)
  - Hypotension (Addison’s)
- Respiratory Rate:
  - Typically Normal
  - Tachypnoea (DKA)
- Temperature:
  - Hyperthermia (Hyperthyroidism)
  - Hypothermia (Hypothyroidism)
Hands:
- Warm, Well Perfused, ↓CRT,Erythema,Sweaty (Hyperthyroidism/Phaeochromocytoma/Acromegaly)
- Cool, Poorly Perfused, ↑CRT, P.Cyanosis, Dry (Hypothyroidism)
- Tremor (Hyperthyroidism, Phaeochromocytoma)
- Clubbing/Thyroid Acropathy (Grave’s Disease[Hyperthyroidism])
- Plummer’s Nails/Onycholysis (Grave’s Disease [Hyperthyroidism])

- Brittle Nails (Hypothyroidism)
- Palmar Crease Pigmentation (Addison’s Disease)

- Large, Spade-like Hands (Acromegaly)
- Osteoarthritic Heberton’s & Bouchard’s Nodules (Acromegaly)
- Xanthomata (Hypothyroidism, Diabetes, Cushings, Acromegaly, PCOS)
Arms:
- Proximal Myopathy (Hyperthyroidism, Hypothyroidism, Cushing’s, Acromegaly)
- Hyperreflexia (Hyperthyroidism); Hung Reflexes (Hypothyroidism)
- Muscle Wasting (Diabetes, Addison’s)
Face:
- (Conjunctival Pallor, Central/Peripheral Cyanosis)
- Receding Hairline + Loss of Lateral 1/3 Eyebrow + Periorbital Myxoedema (Hypothyroidism)
- Exophthalmos + Lid Lag (Hyperthyroidism)

- Xanthelasma (Hypothyroidism, Diabetes, Cushing’s, Acromegaly, PCOS)
- Bitemporal Hemianopsia (Pituitary Adenomas ➔ Cushing’s, Hyperthyroidism, Acromegaly, Prolactinoma, Conn’s)
- Fundoscopy (Hypertensive & Diabetic Retinopathy)
- Buccal Hyperpigmentation (Addison’s)
- Mouth Infections (Diabetes, Cushings)
- Facies:
  - Moon Facies (Cushings),
  - Frightened Stare (Graves – Hyperthyroidism)
  - Anhedonic + Puffy Eyes (Hashimotos – Hypothyroidism)
  - Frontal Bossing, Enlarged Jaw/Tongue/Nose/Ear/Brow (Acromegaly)
  - Hyperpigmented + Wasting (Addison’s)
  - Hirsutism + Receding Hairline (PCOS)
Neck:
- Thyroid Gland Examination:
  - General Inspection:
    - Thyroidectomy Scars
    - Goitre (Hyperthyroidism/Hypothyroidism)
    - Swallow Test (Is it mobile?)
  - Palpation From Behind:
    - Locate Thyroid Gland (2cm below laryngeal prominence)
    - Goitre (Hyper/Hypo) – Size, Consistency, Tenderness, Mobility, Thrill
    - Swallow Test (Mobility)
    - Cervical Lymphadenopathy (Grave’s & Hashimoto’s)
  - Auscultate:
    - Thyroid Bruits (Hyperthyroidism)
  - Retrosternal Goitre?:
    - Pemberton’s Sign
    - Abdominojugular Reflux
    - ↑JVP
    - Percuss Across Sternum

- Acanthosis Nigricans (Diabetes, Cushing’s, Acromegaly, PCOS)

- Buffalo Hump & Supraclavicular Fat Pads (Cushing’s)

- Carotid Bruits (Diabetes, Cushing’s, Acromegaly, PCOS)
Chest:
- Hair Distribution (PCOS)
- Gynaecomastia (Hyperthyroidism, Cushing’s, Acromegaly)

■

- Bony Tenderness (Cushings[Osteoporosis], Hyperparathyroidism[Osteoclast], Acromegaly[Growth])
- Hypertrophic Cardiomyopathy (Acromegaly) ➔ Murmurs, Displaced Apex Beat
- Pericardial Effusion + Pleural Effusion (Hypothyroidism)
- Molluscum Fibrosum in Axilla (Acromegaly)
Abdomen:
- Central Adiposity (Type2Diabetes, Cushing’s)
- Obesity (Type2Diabetes, Cushing’s, Hypothyroidism, PCOS[Metabolic Syndrome])
- Striae (Cushing’s)

- Fat Atrophy @ Injection Sites (Diabetes)
- Hepatomegaly (Diabetes[fatty liver], PCOS[fatty liver], Acromegaly[GH stimulation])
- Hepatomegaly + Splenomegaly + Renal Enlargement (Acromegaly)
- Adrenal Masses (Cushing’s, Addison’s, Conn’s, Phaeochromocytoma)
- Ovarian Masses (PCOS)
- ↑Bowel Sounds (Hyperthyroidism); ↓Bowel Sounds (Hypothyroidism)
Legs:
- Proximal Myopathy (Hypethyroidism, Hypothyroidism, Cushing’s, Acromegaly)
- Quadriceps Atrophy (Diabetes)
- Fat Atrophy @ Injection Sites (Diabetes)
- Pretibial Myxodema (Hyperthyroidism); Non-Pitting Oedema (Hypothyroidism)

- Shiny, Hairless Skin + Pitting Oedema (Diabetes➔PVD)
- Charcot’s Joint (Diabetes)

- Arterial/Venous Ulcers (Diabetes)
- Hyperreflexia (Hyperthyroidism); Hung Reflexes (Hypothyroidism)
- Foot-Drop (Acromegaly[Common Peroneal Nerve Entrapment])
Feet:
- Tendon Xanthomata (Hypothyroidism, Diabetes, Cushing’s, Acromegaly, PCOS)
- Warm, Well Perfused, Erythema, ↓CRT, Sweaty (Hyperthyroidism, Acromegaly)
- Cool, Poorly Perfused, ↑CRT, P.Cyanosis, Dry (Hypothyroidism)
Diabetic Leg & Foot Exam:
- General Inspection:
  - Quadriceps Wasting (Diabetic Amyotropy)
  - Shiny Skin + Hair Loss + Pitting Oedema + Venous Stasis Ulcers
  - Arterial Ulcerations
  - Neuropathic Ulcerations
  - Necrobiosis Diabeticorum
  - Tendon Xanthomata
  - Peripheral Perfusion + CRT + Peripheral Pulses
  - Bunions (Hyperkeratosis on Pressure Points)
  - Halux Valgus, Pes Cavus, Loss of Transverse Arch, Hammer Toes
  - Fungal Infections of Nails & Between Toes
- Neurological Testing (Pt’s Eyes Closed)
  - Monofilament[light touch] on 10 Areas of Feet
  - Monofilament[light touch] on All Dermatomes of Leg
  - Vibration Sense – Start as distally as possible
  - Proprioception Sense
  - Pain Sense – Over All Dermatomes of Leg
  - Muscle Power
  - Reflexes

Diabetic Patient Focused Examination:

Introduction + Wash Hands + Consent
General Inspection:
- Obese Body habitus
- Acanthosis Nigricans
- Xanthelasma
- Fat Atrophy @ Insulin Injection Sites
- Endocrine Facies (Cushing’s, Acromegaly, PCOS)
- Pigmentation (Haemochromatosis)
Vital Signs:
- Tachycardia (if Dehydrated)
- Hypotension (if Dehydrated)
- Tachypnoeic (If DKA)
- Febrile (If Infection)
Lower Extremities:
- General Inspection:
  - Quadriceps Wasting
  - Fat Atrophy @ Insulin Injection Sites
  - PVD: Hair Loss + Shiny Skin + Oedema + Venous Ulcers
  - Arterial Ulcers
  - Neuropathic Ulcers
  - Charcot’s Joint
  - Pes Cavus, Loss of Transverse Arch, Hammer Toes, Halux Valgus
  - Fungal Nail Infections
  - Infections/Cuts Between Toes
- Palpation:
  - Muscle Wasting
  - Temperature
  - Perfusion (CRT & Pulses)
- Neurological Examination – Patient’s Eyes Closed:
  - Soft Touch (Monofilament):
    - All 10 Areas of the foot
    - All Dermatomes of the Leg
  - Vibration:
    - Tuning Fork on Toes
  - Proprioception:
    - Big Toe
  - Pain:
    - All Dermatomes of Leg (But NOT the sole of foot)
  - Muscle Power:
    - All movements
  - Muscle Reflexes:
    - Patellar Tendon
    - Archilles Tendon
    - Babinski (Positive if Upgoing)(Normal = Downgoing)
- Further Examinations & Tests:
  - Cardiovascular Examination
  - Respiratory Examination
  - Eye Exam + Fundoscopy
  - BSL + Urine Dipstick + HBA1C
  - Candida Mouth Infections
  - Acetone Fetor
  - Carotid & Renal Bruits
  - Hepatomegaly (Fatty Liver/Haemochromatosis)

Hyperthyroid Focused Examination:

Introduction + Wash Hands + Consent
General Inspection:
- Weight Loss
- Flushing
- Sweating
- Anxiety
- Frightened Stare + Exophthalmos
- Goitre
- Hoarseness
Vital Signs:
- Tachycardia
- Hyperthermia
- Hypertension
Hands:
- Hands Warm, Well Perfused, ↓CRT, Sweaty, Erythematous
- Hyperthyroid Acropathy (Clubbing, Swelling & Redness of Fingers)
- Onycholysis/Plumber’s Nails (Separation of Nails from Nailbed)
- Hand Tremor
Arms:
- Proximal Myopathy (Weakness Abducting Arm)
Face:
- (Standard check for: Conjunctival Pallor, Central Cyanosis, Peripheral Cyanosis)
- Frightened Stare + Exophthalmos + LID LAG
- Bitemporal Hemianopsia (If Central Hyperthyroidism)
- Pemberton’s Sign
- Fundoscopy (hypertensive changes)
Neck:
- Thyroid Examination:
  - General Inspection:
    - Thyroidectomy Scars
    - Goitre
    - Swallow Test
  - Palpation (From Behind):
    - Locate Thyroid (2cm below Laryngeal Prominence)
    - Palpate Size, Consistency, Nodules, Mobility, Thrills, Tenderness
    - Swallow test (Mobility)
  - Percuss:
    - Retrosternal goitre
  - Auscultate:
    - Thyroid Bruits
- Cervical Lymphadenopathy:
  - Submental/Submandibular/Pre-Auricular/Post-Auricular/Occipital/Jugular Chain/Posterior Triangle)
Chest:
- Gynaecomastia
Abdomen:
- Hepatojugular Reflux (Retrosternal Goitre)
Legs:
- Pretibial Myxoedema
- Proximal Myopathy
Feet:
- Warm, Well Perfused, ↓CRT, Erythema, Sweaty
Thank Patient “That concludes my examination, now I’d like to run some tests”

Hypothyroid Focussed Examination:

Introduction + Wash Hands + Consent
General Inspection:
- Hypothyroid Facies (Apathetic, Puffy Eyes, Loss of Lateral Eyebrows, Thinning of Hair)
- Obesity
- Oedema
- Mental Slowness & ↓Affect
Vital Signs:
- Bradycardia
- Hypothermia
- Hypertension
Hands:
- Cool, Poorly Perfused, ↑CRT, Peripheral Cyanosis, Dry
- Brittle nails
- Xanthomata
- Palmar Crease Pallor + Koilonychia (Menorrhagia)
- Inverse Prayer Test for Carpal Tunnel
Arms:
- Proximal Myopathy (Abduction Weakness)
- Hung Reflexes
Face:
- Conjunctival Pallor (Menorrhagia)
- Central/Peripheral Cyanosis
- Loss of Lateral 1/3 of Eyebrow
- Periorbital Myxoedema
- Xanthelasma
- Fundoscopy (Hypertensive Changes)
Neck:
- Thyroid Examination:
  - General Inspection:
    - Thyroidectomy Scars
    - Goitre
    - Mobility (Swallow Test)
  - Palpation (From Behind):
    - Locate Thyroid Gland (2cm Below Laryngeal Prominence)
    - Goitre (Hyper/Hypo) – Size, Consistency, Tenderness, Mobility, Thrill
    - Swallow Test (Mobility)
  - Cervical lymphadenopathy:
    - Submental/mandibular, Pre/Post-Auricular, Occipital, Jugular Chain, Post-Triangle
- Pemberton’s Sign (Retrosternal Goitre)
- ↑JVP
Chest:
- Percuss for Retrosternal Goitre
- Pericardial Effusion (Soft Heart Sounds)
- Plerual Effusion (Stony Dullness)
Abdomen:
- Abdominojugular Reflux (Retrosternal Goitre)
- Obesity
Legs:
- Non-Pitting Oedema
- Proximal Myopathy (Squat)
- Hung Leg Reflexes
Feet:
- Cool, Poorly Perfused, ↑CRT, Pale, Dry
- Xanthomata
Thank patient “that concludes my examination”, I’ll go organise further tests.

Cushing’s Focussed Examination:

Introduction + Wash hands + Consent
General Inspection:
- Central Adiposity
- Obesity
- Moon Facies
- Buffalo hump
- Striae
- Hirsutism
Vital Signs:
- Hypertension
Hands:
- Warm & Well Perfused, Normal CRT
- Standard: No Palmar Crease Pallor
- Xanthomata
Arms:
- Easy Bruising
- Poor Wound Healing
- Proximal Myopathy (Ab/Adduction)
Face:
- Characteristic Moon Facies
- Xanthelasma
- Fundoscopy (Hypertensive & Hyperglycaemic Changes)
- Bitemporal Hemaniopsia (if Pituitary Adenoma)
- Mouth Infections
Neck:
- Carotid Bruits (Hypercholesterolaemia)
- Acanthosis Nigricans
Chest:
- Gynaecomastia
- Bony Tenderness (Osteoporosis)
Abdomen:
- Central Adiposity
- Striae
- Adrenal Masses
Legs:
- Easy Bruising
- Poor Wound Healing
- Proximal Myopathy (Squat)
Feet:
- Tendon Xanthomata

Acromegaly Focussed Examination:

Introduction + Wash Hands + Consent
General Inspection:
- Acromegalic Facies – Frontal Bossing, Prominent Jaw/Brow Ridge/Nose/Lips/Tongue
Vital Signs:
- Hypertension
Hands:
- Large Spade-Hands
- Warm & Well Perfused, ↓CRT, Palmar Erythema, Sweaty-Greasy Hands
- Thickened Skin
- Xanthomata
- Osteoarthritis (Heberton’s Nodules, Bouchard’s Nodules)
Arms:
- Proximal Myopathy (Ab/Adduction)
Face:
- Acromegalic Facies – Frontal Bossing, Prominent Jaw/Brow Ridge/Nose/Lips/Tongue
- Xanthelasma
- Bitemporal Hemianopsia (Pituitary Adenoma)
- Fundoscopy (Hypertensive Changes)
Neck:
- Acanthosis Nigricans
- Carotid Bruits (due to ↑cholesterol)
Chest:
- Gynaecomastia
- Bony Tenderness (Ribs & Spine) due to Osteoarthritis
- Molluscum Fibrosum in Axillae (Skin Tags)
- Hypertrophic Cardiomyopathy (Displaced Apex Beat, Murmurs & Signs of CCF)
Abdomen:
- Hepatomegaly
- Splenomegaly
- Renal Enlargement
Legs:
- Proximal Myopathy (Squat)
Feet:
- Enlarged Feet
- Warm, Well-Perfused, ↓CRT, Erythema, Sweaty
- Tendon Xanthomata
Thank patient “that concludes my examination”, I’ll go organise further tests.

Addison’s Disease Focussed Examination:

Introduction + Wash hands + Consent
General Inspection:
- Wasting (Weight Loss)
- Hyperpigmentation
- Obvious Fatigue
- Mental Slowness
Vital Signs:
- Hypotension (Hypovolaemia)
- Tachycardia (Hypovolaemia)
Hands:
- Warm & Well Perfused, Normal CRT,
- Palmar Crease Pigmentation
Arms:
- Generalised Muscle Weakness
- Muscle Wasting
Face:
- Wasting (thin face)
- Hyperpigmented + Pigmented Buccal Mucosae
- Dry Mucosae (Dehydration)
Abdomen:
- Adrenal Masses
Legs:
- Generalised Muscle Weakness
- Muscle Wasting
Feet:
- Warm & Well Perfused, Normal CRT,

PCOS Focussed Examination:

Introduction + Wash Hands + Consent
General Inspection:
- Hirsutism (Hair + Acne)
- Receding Hairline
- Obesity (Metabolic Syndrome)
- (Not Pregnant[infertile])
Vital Signs:
- Hypertension
Hands:
- Warm & Well Perfused
- No Palmar Crease Pallor
- Hirsutism (Hairy Dorsum of Hands)
- Xanthomata
Arms:
- Hirsutism (↑Hair)
Face:
- Xanthelasma
- Fundoscopy (Diabetic & Hypertensive Retinopathy)
- Hirsutism (Facial Hair & Acne)
- Deepening Voice
Neck:
- Acanthosis Nigricans (Metabolic Syndrome)
- Carotid Bruits (↑Cholesterol)
Chest:
- Hirsutism (Chest Hair)
Abdomen:
- Ovarian masses/Tenderness
- PV Examination
- Central Adiposity (Metabolic Syndrome)
Legs:
- Hirsutism (hair)
Feet:
- Tendon Xanthomata

Pituitary Disorders (Symptom Cluster):

Space-Occupying Lesions – (Eg. Adenomas):
- ➔Compression of Optic Chiasm ➔ Visual Field Defect (Bitemporal Hemianopia)
- ➔Compression of Extrinsic Ocular Muscles ➔ Oculomotor Palsies (“Ophthalmoplegia”)
- ➔ Increased Intracranial Pressure ➔ Headaches
Increased Hormone Secretion ➔Hyperpituitarism:
- Anterior Pituitary:
  - Eg. ↑PRL – Due to Prolactinoma ➔ Galactorrhoea
  - Eg. ↑GH – Pit. Tumour ➔ Gigantism (Kids)/Acromegaly(Adults)
  - Eg. ↑ACTH – Pit. Tumour ➔ Cushing’s Disease
  - Eg. ↑FSH/LH – Pit./Hypothalamic Tumour ➔ Precocious Puberty
  - Eg. ↑TSH – (Rare) Pit. Tumour ➔ Primary Central Hyperthyroidism
- Posterior Pituitary:
  - Eg. ↑ADH – Hypothal.Osmorecep.Dysfunction ➔ SIADH
Decreased Hormone Secretion ➔ Pan-Hypopituitarism: (Eg. Sheehan’s Disease: Post-Partum Hypopituitarism)(Eg. Pituitary Apoplexy/ Infarction)
- Initially Asymptomatic
- Later:
  - 2^o Hypothyroidism
  - 2^o Adrenal Insufficiency (Similar to Addisons)
  - 2^o Dwarfism (GH Deficiency)
- (In Sheehan’s Syndrome):
  - Agalactorrhoea (No Lactation)
  - /Amenorrhoea after Delivery.

SIADH:

(Hypothalamic Dysfunction ➔ ↑ADH)

1. Fluid Overload Without Oedema or Hypertension
2. Hyponatraemia (Dilutional + ↑Excretion):
- If Severe ➔ Cerebral Oedema ➔
  - Nausea/Vomiting
  - Headache/Confusion/Seizures/Coma
3. High [Sodium] in Urine
4. High Urine Osmolarity (relative to Plasma Osmolarity)
5. Normal Renal & Adrenal Function

Diabetes Insipidus: (ADH Deficiency or Renal ADH Insensitivity)

Polydipsia (Extreme Thirst)
Polyuria (Excessive Urination)
Risk of Hypokalaemia
Risk of Dehydration (If water isn’t available)

Hyperthyroidism & Thyrotoxicosis: (Eg. Graves Disease or Central ↑TSH)

TYPICAL Symptoms/Presentation:
- Fatigue,
- Weight Loss (Despite ↑Appetite)
- Diarrhoea
- Heat intolerance, ↑Sweating, Facial Flushing
- Irregular Menstruation
- Painless Goiter
- Anxiety, Tremor, Insomnia,
- Palpitations
- (NB: May ➔ CCF in Elderly)
TYPICAL Clinical Signs:
- Vitals:
  - Tachycardia (Irreg.Irreg: AF), Hyperthermia, Hypertension,
- Other:
  - Weight Loss, Flushing, Anxiety, Sweating, Tremor, Allopecia, Frightened Facies
  - Hands Warm & Well Perfused, Palmar Erythema, Sweaty Hands, Acropathy (Digital Clubbing & Swelling; Fingers & Toes) –GRAVES, Onycholysis (Plummer’s Nails = Separation of Nails from Nailbed), Hand Tremor,
  - Proximal Myopathy (Muscle Weakness) & Wasting, But HYPERREFLEXIA
  - Exophthalmos (Frightened Facies), Lid Lag,
  - Neck Scars (Thyroidectomy ➔ ↑Exogenous Thyroid Hormone), Palpable Painless Goitre (Diffuse if Grave’s Disease; Nodular if TMG), Mobile on Swallowing, Cervical Lymphadenopathy (Graves)
  - Thyroid Bruit
  - Check Pemberton’s Sign (Retrosternal Goitre) & Percuss Across the Chest
  - Gynaecomastia
  - Pretibial oedema, HYPERREFLEXIA
- Signs of Causes:
  - Goiter
  - Pituitary Adenoma (Bitemporal Hemianopsia)

Hypothyroidism & Myxoedema: (Hashimoto Thyroiditis, Iodine Deficiency or Central ↓TSH)

TYPICAL Symptoms/Presentation:
- Early symptoms:
- Fatigue, Depression
- Weight Gain (Despite ↓Appetite)
- Constipation
- Cold Intolerance, Dry Skin, Pale Skin
- Menorrhagia
- Painless Goiter
- Stupour, Memory Loss
- Muscle Pain
- Puffy Eyes, Hair Loss of Eyebrows
TYPICAL Clinical Signs:
- Vitals:
  - Bradycardia (Small Volume), Hypotension, Hypothermia
- Other:
  - Obesity, Oedema, Mental Sluggishness, Anhedonia, Slow Hypothyroid Speech, Hoarseness, Apathetic (Emotionless) Face,
  - Hands Cool, Dry & Poorly Perfused, ↑CRT, Peripheral Cyanosis, Brittle Nails, Palmar Crease Pallor (from Menorrhagia), Inverse Prayer Test for Carpal Tunnel, Xanthomata (↑Cholesterol)
  - Proximal Myopathy (Muscle Weakness) & Wasting, with “HUNG REFLEXES”
  - Facial Oedema, Periorbital Oedema, Allopecia, Loss of lateral 1/3 eyebrows, Xanthelasma (↑Cholesterol)
  - Painless Goitre, Mobile on Swallowing,
  - Pericardial Effusion, Pleural Effusions
  - Pedal Oedema, Hung Leg Reflexes, Peripheral Paresthesia
- Signs of Causes:
  - - Cretinism (Iodine Deficiency)

Hyperparathyroidism: (↑PTH➔Hypercalcaemia & Hypophosphataemia)

TYPICAL Symptoms/Presentation:
- (F>>M)
- Asymptomatic – Incidental Hypercalcaemia.
- Symptomatic – “Bones, Moans, Stones & Abdominal Groans”:
  - Bone: Pain/Osteoporosis/Fractures
  - CNS: Depression/Lethargy/Seizures
  - Gallstones & Kidney Stones.
  - Abdo: Constipation/Nausea/Ulcers
- Other Organs: Metastatic Calcification in Stomach/Lungs/Myocardium/Heart Valves/ &Vessels
TYPICAL Clinical Signs:
- Vitals:
  - NA
- Other:
  - Mental State (Hypercalcaemia can ➔Coma & Convulsions)
  - Signs of Dehydration (Hypercalcaemia can ➔ Polyuria)
  - Band Keratopathy (Calcium Deposition underneath the Corneal Epithelium)

- - Bony Tenderness (Shoulders, Sternum, Ribs, Spine, Hips)
  - Pseudogout (Calcium Pyrophosphate deposition in the knee)
  - Haematuria (Renal Stones)
- Signs of Causes:
  - ↑PTH 2^o to Chronic Renal Failure (CKD Signs + Osteoporosis)

Hypoparathyroidism:(↓PTH➔Hypocalcaemia ➔ Tetany)

TYPICAL Symptoms/Presentation:
- (Typically Post-Operative after Thyroidectomy)
- *Hypocalcaemia ➔ Neuromuscular **Tetany**:
  - ➔ Distal Paraesthesias
  - ➔ Cramping & Spasms
  - ➔ *Laryngospasm (Emergency)
  - ➔ Seizures
- (+/- CNS: Confusion/Depression/Psychosis)
- (+/- CVS: Characteristic Prolonged QT-Interval)
TYPICAL Clinical Signs:
- Vitals:
  - NA
- Other:
  - Trousseau’s Sign (Tetany of hand after 2mins of arm ischaemia with BP Cuff)
  - Chvostek’s sign (Unilateral Facial Twitch when the Facial Nerve Outlet is Struck)
  - Hyperreflexia
  - Fragile Nails
  - Dry Skin
  - Tooth Deformities
- Signs of Causes:
  - Neck Scars (Thyroidectomy)

Disease:

TYPICAL Symptoms/Presentation:

Type 1 Diabetes:

Absolute Insulin Deficiency

Juvenile Disease; Rapid onset:

Polyuria, Polydipsia, Polyphagia Rapid Weight Loss Despite ↑Appetite Nausea, Vomiting

Fatigue

(+ LADA➔ Slowly Progressing “Type I Diabetes”):

Typically Slim Adults (≈40yrs)

Slow Progression to Insulin Dependency Same symptoms as D1M.

Type 2 Diabetes:

Insulin Resistance And/Or Relative Insulin Deficiency

Adult Disease; Slow, insidious onset:

Polyuria, Polydipsia, Polyphagia Usually Overweight (Central Obesity) No Ketonuria

Metabolic Syndrome

Central Obesity
Hypertension
Impaired Glucose Tolerance
Dyslipidaemia (↑TGLs, ↓HDL)

(+MODY: Genetic – Autosomal Dominant):

Young People, Non-Obese Syx of Hyperglycaemia – PPP

TYPICAL Clinical Signs Common To Diabetes:

Vitals:

Tachycardia (if Dehydration), Postural Hypotension (if Dehydration), Tachypnoea (if DKA)

Other:

Wasting (If Type 1), Obesity (If Type 2) Fat Atrophy @ Insulin Injection Sites

Face:

Visual Acuity, Fundoscopy (Retinopathy–Dots/Blots), Cataracts, Xanthelasma, Sweet Breath (DKA)

Mouth Infections (Candida) Carotid Bruits (PVD) Acanthosis Nigricans

Go From Face to Lower Limbs:

Inspection: Ulcers, Hyperkeratosis, Shiny Skin, Hair Loss, Fungal Nail Infections, Cellulitis, “Necrobiosis Lipoidica Diabeticorum” (Disgusting-looking Ulcer), “Charcot’s Joint” (Poor Proprioception), Hallux Valgus, Pes Cavus, Hammer Toes, Loss of Transverse Arch

Palpation: Cool Feet, ↑CRT, ↓Distal Pulses, Pedal Oedema,

Neurological: Monofilament (in 9 Areas of the Foot), Vibration, Proprioception, Pain (All Leg Dermatomes EXCEPT on Soles of Feet), Reflexes

Signs of Causes:

Cushings Facies, Acromegaly Facies, Pigmentation (Haemochromatosis)

Further Examination:

CVS (PVD), CKD (Renal), Full Neurological,

Diabetic Ketoacidosis: (Only in D1M or LADA)

TYPICAL Symptoms/Presentation:
- Polyuria, Polydipsia, Polyphagia
- Ketoacidosis ➔
  - Hyperventilation
  - Headache/Altered Mental State
  - Vomiting➔Dehydration, ↓Na, ↓Ca,
TYPICAL Clinical Signs:
- Vitals:
  - Tachycardia (+/- Arrhythmia), Hypotension, Tachypnoea
- Other:
  - Sweet Breath (Acetone Breath)
  - ALOC (↓GCS)
  - Dehydration Signs (Loss of Skin Turgor, Enophthalmos, Dry Mucosae)
  - Kussmaul’s Breathing (A form of Hyperventilation: Deep, Laboured Breathing)
- Signs of Causes:
  - Diabetes (Insulin Injection Sites, Diabetes Bracelet, Peripheral Neuropathy, CKD)
- (NB: Hypokalaemia in DKA is a RED FLAG)
- Treatment:
  - IV access ➔ Correct Dehydration
  - Insulin + Potassium Supp. ➔ Correct Hyperglycaemia & Electrolytes
  - Treat underlying cause (Infection)

HONC – Hyperosmolar Non-ketotic Crisis: (Only in D2M)

TYPICAL Symptoms/Presentation:
- (NB: NO Ketogenesis – Even Low Insulin is enough to Inhibit Ketogenesis).
  - Hyperglycaemia
  - Polyuria (Osmotic Diuresis) & Dehydration
  - Hyperviscosity ➔ ↑Risk of Thrombosis
  - Mental Impairment (Stupor/Coma)
TYPICAL Clinical Signs:
- Vitals:
  - Tachycardia (Dehydration), Hypotension (Dehydration)
- Other:
  - Signs of Dehydration
  - Tremor
  - ALOC (Stupor/Coma)
  - Neurology – (Sensory/Motor Impairment, Focal Seizures, Hyporeflexia, Tremors)
- Treatment:
  - IV Fluids
  - Insulin + Potassium (Since Insulin causes K⁺ Shift Into Cells)

Hypoglycaemia: (Eg. Insulinoma, Insulin Overdose, Missed Meal)

TYPICAL Symptoms/Presentation:
- Polyphagia
- Tremor
- ALOC (Confusion, Drowsiness, Seizures, etc)
TYPICAL Clinical Signs:
- Vitals:
  - Tachycardia,
- Other:
  - Sweating, Anxiety, Tremor, Palpitations
  - Confusion, Drowsiness, Visual Disturbances, Seizures, Coma
- Signs of Causes:
  - Mental Illness (Suicide Attempt),
- Treatment:
  - #1 – Give conservative dose of Oral/IV Glucose OR – IM/IV Glucagon

Cushing’s Disease:(Hyper-Cortisolism)(Central – Pituitary Adenoma; or Exogenous Steroids)

TYPICAL Symptoms/Presentation:
- Weight Gain
- Change in Appearance (Moon Facies)
- Mood Swings/Depression/Psychosis
- + Hirsutism & Menstrual Abnormalities

TYPICAL Clinical Signs:
- Vitals:
  - Hypertension
- Other:
  - Moon Facies, Central Adiposity (Weight Gain), Striae, Buffalo Hump, Supraclavicular Fat Pads
  - Thin Skin, Easy Bruising, Poor Wound Healing
  - Hirsutism (in Females)
  - Visual Field Testing for Pituitary Tumour
  - Immunocompromise (Candida in Mouth, Fungal Nail Infections)
  - Ask Pt to Squat (Proximal Limb Muscle Atrophy & Weakness)
  - Bony Tenderness or Vertebral Bodies (Osteoporosis)
  - ↑Cortisol ➔ ↑Gluconeogenesis & Insulin Resistance➔➔ 2^oDiabetes:
    - Hyperglycaemia ➔ Polyuria, Polyphagia, Polydipsia
  - Osteoporosis, Backache
- Signs of Causes:
  - Bodybuilders? (Exogenous Steroid Use)
- Diagnosis: Negative Dexamethasone Suppression Test

Conn’s Disease: (Hyper-Aldosteronism) (Pituitary Adenoma, Adrenal Hyperplasia, Carcinoma)

TYPICAL Symptoms/Presentation:
- (↑Aldosterone➔Hypernatraemia(& Hypokalaemia))
- Renal Fluid Retention ➔
  - ***Hypertension (Often the ONLY Syx)
  - Hypernatraemia ➔ Neuromuscular Syx (Paraesthesia/Weakness/VisualΔ/Tetany)
TYPICAL Clinical Signs:
- Vitals:
  - ***Hypertension
- Other:
  - Paraesthesia/Weakness/VisualΔ/Tetany
  - Ballott Kidneys for Adrenal Tumours
- (NB: Hypertension can ➔ LVH, ↑Risk of CVA & MI)

Phaeochromocytoma: (Hyper-Adrenalinism) (Idiopathic or MEN2 Tumour Syndrome)

TYPICAL Symptoms/Presentation:
- Symptoms:
  - Palpitations/Tachycardia
  - Headache (Hypertension)
  - Sweating/Hot Flushes/Tremor
  - Anxiety
  - Nausea/Vomiting
TYPICAL Clinical Signs:
- Vitals:
  - Paroxysmal Hypertension, Tachycardia,
- Other:
  - Warm Sweaty Peripheries, ↓CRT, Facial Flusing, Pinpoint Pupils,
  - Cardiac Flow Murmurs (Hyperdynamic Circulation), ↑Bowel Sounds,
  - Ballott Kidneys for Adrenal Tumour
- Complications of Hypertension:
  - Congestive Heart Failure & Pulmonary Oedema (Dyspnoea, PND, Orthopnoea, Inspiratory Creps, RV Heave, ↑JVP)
  - Myocardial Infarction
  - Ventricular Fibrillations
  - CVAs

Addison’s Disease: (CHRONIC Adrenal Insufficiency) (Autoimmune Adrenalitis)

TYPICAL Symptoms/Presentation:
- (↓↓Aldosterone & ↓↓Cortisol)
- Insidious Onset:
  - Weakness, Fatigue, Lethargy, Depression
  - Anorexia, Weight Loss,
  - Vomiting, Diarrhoea
  - Skin Hyperpigmentation
  - Polyuria ➔ Dehydration (↓Aldosterone)
TYPICAL Clinical Signs:
- Vitals:
  - Postural Hypotension (Hypovolaemia)
- Other:
  - Cachexia, Pigmentation (Palmar Creases, Elbows, Gums, Buccal Mucosa) [due to melanocyte- stimulating activity of ACTH],
  - Generalised Weakness
  - Dehydration Signs (Loss of Skin Turgor, Enophthalmos, Dry Mucosae)
- Diagnosis:
  - Clinical Diagnosis
  - Synacthen Test (Measure Cortisol & Aldosterone 30mins after ACTH Injection)
  - Hypoglycaemia (Due to Glucocorticoid (Counter-Reg) Deficiency)

Waterhouse-Friderichsen Syndrome:

(ACUTE Adrenal Insufficiency due to Meningococcal Sepsis ➔ Adrenal Infarction)

TYPICAL Symptoms/Presentation:
- Abrupt & Severe Clinical Course
  - ↓Aldosterone ➔ Na & H2O Loss ➔ Hypovolaemic Shock
- (Death in Hours-Days unless Treated)
- + Symptoms of Meningococcal:
  - Fever
  - Headache
  - Photophobia
  - Neck Stiffness

TYPICAL Clinical Signs:
- - - Vitals:
      - Fever (Due to Meningococcal)
    - Other:
      - Kernig’s Sign (Pain on Hip Flexion & Knee Extension) & Brudzinski’s Sign (Neck Flexion causes Involuntary Hip & Knee Flexion), Photophobia, Headache,
      - Petechiae (Skin, Mucosae, Conjunctiva)
    - Signs of Causes:
      - Typically Meningococcal Septicaemia
      - :. Neck stiffness
      - :. DIC

Polycystic Ovaries PCOS: (Hyper-Androgenism) (Genetic – Sex-Limited Autosomal Dominant)

TYPICAL Symptoms/Presentation:
- (↓Conversion of Androgens ➔Oestrogen ➔ Hyperandrogenism)
  - 1. Infertility: Due to Anovulation
  - 2. Menstrual Changes: Amenorrhoea ➔ Infertility
  - 3. Masculinisation: Acne, Hirsutism (↑Hair), Deepening Voice
  - 4. Metabolic Syndrome (“Synd. X”): Insulin Resistance (+/- Obesity, D2M, ↑Cholesterol)
TYPICAL Clinical Signs:
- Vitals:
  - Hypertension
- Other:
  - Hirsutism (Facial hair, deepening voice, acne)
  - Metabolic Syndrome (Obesity, Xanthelasma, Xanthomata, Acanthosis Nigricans, Polyuria, Polydipsia, Polyphagia)
  - Palpate Abdomen for Ovarian Masses

Thank You so Much. Happy Learning!!

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