MEDICAL SUCCESS INSIDERS (MSI)

MEDICAL SUCCESS INSIDERS (MSI)

© DR. JOSEPH @ WWW.MSIMASTERCLASS.COM ALL RIGHTS RESERVED SIGN UP IN WWW.FRIENDOCT.COM TO ASSESS TO SOFTCOPY

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Forewords

First of all, thank you for purchasing this book and I am very

glad that you have taken your first step to bring your examination techniques and interpretation skill to another advanced level. I can guarantee you that after reading this book, your understanding towards the clinical examination will be deeper and clearer. This book has divided the clinical examination into two main components, mainly the technique part and interpretation of the findings part. And I strongly believe that you need to master both the technique and interpretation skill in order to help you to come to the diagnosis. This book consists of multiple authenticated references and has been arranged into systematic and organized way to ease the study and revision. The book will be updated from time to time in order for you to get the latest updated information and the contents are subject to change. The online softcopy version will be provided too as long as you have bought this book. Last but not least, I hope that this book will be a good companion in your study and career and let us work together towards the goal and achievement. We hope all the best to you. Cheers. -WE CARE, WE SHARE-

-Dr. Joseph Chia- Founder of Medical Success Insiders (MSI)



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ENDOCRINE

EXAMINATION



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Endocrine Examination Summary: 1.Introduceyourself&askforpermission2.Arrangethepatienttositupright&washhands&removenecessarygarment3.Generalexamination

General:• Agegroup• Sex• Mentalstate• Build• Surroundings• Growchart(paediatrics)Systematic:• Hands• Arms• Head• Face• Eyes• Mouth• Skin• Neck• Chestwall• Abdomen• Genitalia• Legs• Others

4.Thyroid• Hyperthyroidism(thyrotoxicosis)• Hypothyroidism(myxodema)



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5.Parathyroid• Hyperparathyroidism• Hypoparathyroidism• Pseudohypoparathyroidism• Pseudo-pseudohypoparathyroidism

6.Pancreas• Diabetesmellitus• Diabeticfoot

7.Pituitary• Hypopitutarism• Panhypopituitarism• Acromegaly• Pituitarytumor

8.Adrenal• Cushingsyndrome/disease• Addisondisease

9.Gonad10.Others• Carcinoidsyndrome



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Endocrine Examination Details: 1.Introduceyourself&askpermission2.Arrangethepatienttositupright&washhands&removenecessarygarment3.GeneralInspectionTECHNIQUES Ø Dogeneralexamination:

o Agegroupo Sexo Mentalstateo Buildo Surroundingso Growchart(paediatrics)



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4.ThyroidExaminationTECHNIQUES Inspection:Ø Inspecttheneckfromfrontandsideanddecidewhetherthereislocalisedor

generalswellingoftheglandØ Inspectforscarsovertheskinofneckàthyroidectomyscarformsaringaround

thebaseoftheneckØ LookforrednessofskinovertheglandàoccursinsuppurativethyroiditisØ GivepatientaglassofwaterandaskhimtotakeasipØ AskpatienttoswallowandwatchtheneckswellingcarefullyØ SwallowingalsoallowstheshapeoftheglandtobeseenbetterØ AskpatienttoopentheirmouthandthentoputouttheirtongueØ Lookatthepositionofthyroidcartilagewhetherincentreoftheneckordeviatedto

oneside?Ø Alsolookforprominentveins



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Palpation Descriptions&Significance

Site • Midlineorlateral

Size • Itissometimeshelpfultomeasure&recordtheneckcircumference

• Measureanydiscretenoduleswithcalipers• Recordthemaximumneckcircumferenceofalargegoitreusinga

tapemeasure(objectivemeasurementsareusefulforlong-termfollow-up)

Shape • Checkwhethertheglandisuniformlyenlargedorirregularandwhethertheisthmusisaffected

• Checkwhetherthyroiddiffuselyenlargedàthyroidstimulatinghormone(TSH)-mediatedorautoimmuneenlargement

• Ifso,isitsoft(dyshormogenesis,diffusegoitreofpuberty)orfirm/hard(autoimmunethyroiditis)

Surface • Alsodecidewhetherthewholeglandfeelsnodular(multinodulargoitre)

• Checkwhethertwoormoreidentifiablenodules,and,ifso,isthepatientthyrotoxicanddoestheglandextenddownwardbehindthesternum

• Checkwhetherthepalpableabnormalityasinglefocalnoduleàsuggestingacyst,adenomaorcarcinoma

Margin • Feelparticularlycarefullyforlowerborderàbecauseitsabsencesuggestsretrosternalextension

Tenderness • Maypresentinthyroiditis

Consistency • Mayvaryindifferentpartsoftheglandàcanbesoft,firm,orhard

Mobility • Carcinomamaytetherthegland• Repeattheassessmentwhilepatientswallows• Testmotilityinhorizontalplane&verticalplane

Others • Palpatethecervicallymphnodes(maybeinvolvedincarcinomaofthyroid)

• Decideifathrillispalpableoverthegland,asoccurswhentheglandisunusuallymetabolicallyactiveasinthyrotoxicosis

• Feeleachcarotidarterypulsationàabsentmayveryoccasionallyindicatemalignantinfiltrationbythyroidcarcinoma

• Notethepositionoftrachea,whichmaybedisplacedbyretrosternalgland

• Seeanylocalpressureeffectsorlocalinfiltration(e.g.dysphoniafromrecurrentlaryngealinvolvement)

• Alsocheckforanyweightlossanddebilityàsuggestanaplasticcarcinomaorlymphoma



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Percussion:Ø TheupperpartofmanubriumcanbepercussedfromonesidetotheotherØ BeginjustbelowthesuprasternalnotchanddescendtowardssternalangleØ Percussalongclavicles&overthesternumandupperchestwallØ Percussionisusedtodefinethelowerextentofaswellingthatextendsbelow

suprasternalnotchØ Percussionofthelumpintheneckitselfisrarelyhelpful

Auscultation:Ø AuscultateovereachlobeforthyroidbruitØ Athyroidbruitmaybeconfusedwithothersounds(carotidbruitfromcarotidartery

ortransmittedfromaortaarelouderalongthelineofartery)Ø Transientgentlepressureovertherootofneckwillinterrupt/obliterateavenous

humfrominternaljugularveinØ Ifthereisagoitre,applymildcompressiontolaterallobesandlistenagainfor

stridor



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Pemberton'ssignØ GetthepatienttoliftbotharmsashighaspossibleØ Waitafewmoments,thensearchthefaceeagerlyforsignsofcongestion

(plethora)andcyanosisØ AssociatedrespiratorydistressandinspiratorystridormayoccurØ Lookattheneckveinsfordistension(venouscongestion)Ø AskthepatienttotakeadeepbreathinthroughthemouthandlistenforstridorØ Thisisatestforthoracicinletobstructionduetoretrosternalgoitreorany

retrosternalmass



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Hyperthyroidism(thyrotoxicosis)Ø CausedbyexcessiveconcentrationsofthyroidhormonesØ Maybeduetoaccidental/deliberateuseofthyroidhormone(thyroxine)tabletsà

thyrotoxicosisfactitiaØ Antiarrhythmiadrug(amiodarone)àcontaineslargeamountofiodine&cancause

thyrotoxicosisØ Thyrotoxicosisàcharacterizedbysignsofsympatheticoveractivitysuchastremor,

tachycardiaandsweatingØ CatecholaminesecretionisusuallynormalinhyperthyroidismØ Thyroidhormonepotentiatestheeffectsofcatecholamines,possiblybyincreasing

thenumberofadrenergicreceptorsintissuesØ CommonestcauseofthyrotoxicosisinyoungpeopleàGraves'disease

(autoimmunediseasewherecirculatingimmunoglobulinstimulateTSHreceptorsonthesurfaceofthyroidfollicularcells)

Findings Descriptions&Significance Pictures

Generalinspection

• Lookforsignsofweightloss,anxiety,sweating,frightenedfaciesofthyrotoxicosis

Eyes • Eyesignsofthyrotoxicosis:o Lidretraction&lidlago Exophthalmoso Ophthalmoplegiao Chemosis

(A)Lidretraction&lidlag:• Normally,uppereyelidcrosseseyeat

mid-waybetweenpupil&superiorlimbusofiris)

• Ifuppereyelidishigherthannormal&lowerlidisinitscorrectpositionàlidretraction/Dalrymple’ssign(scleravisibleabovetheiris)



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Eyes(Continued)

• Whenupperliddoesnotkeeppacewitheyeballasitfollowsfingermovingfromabovedownwardsàlidlag/vonGraefe'ssign

• Descentofupperlidlagsbehinddescentofeyeball

• Allthesearecausedbyover-activityofinvoluntary(smoothmuscle)partoflevatorpalpebraesuperiorismuscle/duetoautonomicpartoflevatorpalpebraesuperiorismuscleishypertonic

• Ifptosisispresentàshouldruleoutmyastheniagravis

• Patientmayblinklessfrequentlythannormal

(B)Exophthalmos:• Examinetheeyesforexophthalmos

(scleraearenotcoveredbylowereyelid)àstaringorprotrudingeyesanddifficultyclosingeyelids

• Nextlookfrombehindoverthepatient'sforeheadforexophthalmos(eyewillbevisibleanteriortosuperiororbitalmargin)

• Nowexamineforthecomplicationsofproptosis:o Chemosisàoedemaof

conjunctivaandinjectionofsclera,particularlyovertheinsertionoflateralrectus

o Conjunctivitiso Cornealulcerationàdueto

inabilitytoclosetheeyelidso Opticatrophyàrareandpossibly

duetoopticnervestretchingo Ophthalmoplegiaàinferiorrectus

musclepowertendstobelostfirst,andlaterconvergenceisweakened/doublevisioncausedbymuscleweakness



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Hypothyroidism(myxoedema)Ø Hypothyroidismàduetoprimarydiseaseofthyroidor,lesscommonly,is

secondarytopituitaryorhypothalamicfailureØ MyxoedemaàimpliesamoresevereformofhypothyroidismØ Inmyxoedema,hydrophilicmucopolysaccharidesaccumulateintheground

substanceoftissuesincludingskinàresultsinexcessiveinterstitialfluid,whichisrelativelyimmobile,causingskinthickening&doughyinduration


Generalinspection

• Lookforsignsofobviousmentalandphysicalsluggishness,orevidenceof'myxoedemamadness'

• Hypothyroidspeech(characteristicallyslow,nasalanddeepinpitch)àfeatureinaboutathirdofpatients

• Mayhaveobesity/overweight,withexcessconnectivetissueandfatsupraclavicularfossae,acrossthebackofneck&overtheshoulders

[Videoavailableinthesoftcopy]

Hands • Noteperipheralcyanosisàduetoreducedcardiacoutputandswellingofskin,whichmayappearcoolanddry

• Yellowdiscolorationofhypercarotenaemia(slowingdownofhepaticmetabolismofcarotene)maybeseenonthepalms

• Lookforpalmarcreasepallorforanaemiawhichmaybedueto:o Chronicdiseaseo Folatedeficiencysecondaryto

bacterialovergrowth/vitaminB12deficiencyduetoassociatedperniciousanaemia

o Irondeficiencyduetomenorrhagia

• Checkpulseàmaybeofsmallvolumeandslow/bradycardia

• Checkbloodpressureàmaybelow• Boththesechanges(bradycardia&

hypotension)maybereversedifheartfailuredevelops



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Hands(Continued)

• Testforsensorylossàcarpaltunnelisthickenedinmyxoedema

• Handsarepuffyandspade-like

Face • Theskin,butnotsclera,mayappearyellowàduetohypercarotenaemia

• Skinmaybegenerallythickened&alopeciamaybepresent

• Eyelidsbecomeswollenandheavy,makingpatientlooksleepyandlethargic

• Vitiligo(associatedautoimmunedisease)maypresent

• Inspecttheeyesforperiorbitaloedema

• Loss/thinningofouterthirdofeyebrowsàcanoccurinmyxoedema(alsocommoninhealthypersons)

• Lookforxanthelasmaàduetoassociatedhypercholesterolaemia

• Palpateforcoolnessanddrynessofskinandhair

• Theremaybethinningofscalphair• Lookatthetongueforswelling/

enlargementwhichseemstofillthemouthduringspeechandinterferewitharticulationofwords

• Askthepatienttospeakàlistenforcoarse,croaking,slowspeech

• Bilateralnervedeafnessàmayoccurwithendemicorcongenitalhypothyroidism



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CretinismØ Cretinàchildwhosementalandphysicaldevelopmenthasbeenretardedbylackof

thyroidhormoneØ Cretinismàlikelytooccurinthoseplaceswheregoitreisendemic&childmayhave

goitreØ Cretinhasunderdevelopedskeleton(dwarf)&largeprotrudingtongue,eyesare

wideapart,andtheskullisalsowideØ Limbsandneckareshort&handsspade-likeØ Skinisdry&therearesupraclavicularpadsoffatØ Abdomenisdistendedandprotuberant&thereisoftenanumbilicalherniaØ Whenhypothyroidismoccursinolderchildrenàdevelopamixtureofsymptomsof

cretinismandmyxoedema

Conclusion:Ø Onceyouhaveexaminedthepatient,youshouldbeabletodrawconclusionsasto

thenatureandtextureoftheglandandastoitsendocrineactivityØ Natureofgland:

o Solitarypalpablenoduleo Multinodulargoitreo Diffuselyenlargedgland

Ø Activityofgland:o Normalactivity(euthyroid)o Hypersecretion/over-activity(hyperthyroidism/thyrotoxicosis)o Hyposecretion/under-activity(hypothyroidism/myxoedema)



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TypesofhyperparathyroidismTypes Descriptions&Significance

Primary • DuetoexcessPTHsecretion• Causes:

o Adenoma(80%)o Hyperplasiao Carcinoma(rare)

Secondary • Duetoresponseofparathyroidglandstochronichypoglycemia• Causes:

o Hyperplasiafollowingchronicrenalfailure

Tertiary(autonomous)

• Duetoparathyroidglandsbecomeautonomousa=&nolongerrespondtonormalfeedbackmechanism

• Appearanceofautonomoushyperparathyroidismàcomplicationofsecondaryhyperparathyroidism

Comparisonsbetweendifferenttypesofhyperparathyroidismandmalignancy



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HypoparathyroidismØ Resultsinhypocalcaemiawithneuromuscularconsequences(tetany)Ø Usuallyapostoperativecomplicationafterthyroidectomy,butcanbeidiopathicØ Hypocalcaemiacanalsoresultfromend-organresistancetoparathyroidhormoneà

pseudohypoparathyroidismExamination Descriptions&Significance Pictures

Hand • Lookatnailsforfragilityandmonilialinfection

• Noteanyskindryness

Arm • Trousseau’ssignàelicitedwithbloodpressurecuffplacedonthearmwithpressureraisedabovesystolicpressure

• Typicalcontractionofhandoccurswithin2minuteswhenhypocalcaemiahascausedneuromuscularirritabilityàthumbbecomesstronglyadducted,fingersareextended,exceptatmetacarpophalangealjoints

• Appearslikeobstetricianabouttoremoveplacentamanuallyàmaind’accoucheur

Face • Chvostek’ssignàtappinggentlyoverfacialcranialnerveundertheear

• Nerveishyperexcitableinhypocalcaemia&briskmusculartwitchoccursonthesamesideofface



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PseudohypoparathyroidismØ Geneticdisorderinwhichthebodyresistant/failstorespondtoparathyroid

hormoneØ Patientshavetetany(duetohypocalcaemia)aswellastypicalskeletalabnormalities

àshortstature,roundface,shortneck,thinstockybuildandverycharacteristicallyshortfourthorfifthfingersortoes(duetometacarpalormetatarsalshortening,whichcanbeunilateralorbilateral)

Ø Characterizedbyàhypocalcemia,hyperphosphatemia,increasedserumconcentrationofparathyroidhormone(PTH),andinsensitivitytobiologicactivityofPTH

Ø 3types:(a)TypeIa:

o AlsocalledAlbrighthereditaryosteodystrophyo Causesshortstature,roundface,obesity,developmentaldelay,andshort

handbones(b) TypeIb:

o InvolvesresistancetoPTHonlyinkidneyso Lowcalciuminbloodislowo NosymptomsofAlbrighthereditaryosteodystrophy

(c)TypeIIo Lowbloodcalcium&highbloodphosphatelevelso DonothavethephysicaltraitscommoninTypeIa

PseudopseudohypoparathyroidismØ Conditionwheretheindividualhasphenotypicappearanceof

pseudohypoparathyroidismtype1a,butisbiochemicallynormalØ HormoneresistanceisnotpresentinpseudopseudohypoparathyroidismØ Diseasewherethereisnotetany(bloodcalciumconcentrationisnormal),but

characteristicskeletaldeformitiesarepresentØ Comparisons:Conditions Appearance PTH

levelCalcitriol Calcium Phosphate

Hypoparathyroidism Normal Low Low Low High

Pseudo-hypo-parathyroidism

Type1A

Skeletaldefects

High Low Low High

Type1B

Normal High Low Low High

Type2

Normal High Low Low High

Pseudo-pseudo-hypoparathyroidism

Skeletaldefects

Normal Normal Normal Normal



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7.PituitaryExaminationTECHNIQUES AnatomyØ Thepituitaryglandisenclosedinsellaturcicainthebaseofskullbeneaththe

hypothalamusØ Itisbridgedoverbyafoldofduramater(diaphragmasellae)withsphenoidalair

spacesbelow&opticchiasmaboveØ Thepituitaryhas2lobes:

o Anterioràsecretesseveralhormones(ACTH,prolactin,GH,TSH,LH,FSH)o Posterioràextensionofhypothalamus&secretesvasopressin(antidiuretic

hormone)andoxytocin

FINDINGS Ø Causesofhypopituitarism:

o Space-occupyinglesiono Pituitarytumour(non-secretoryorsecretory)o Othertumoursàcraniopharyngioma,metastaticcarcinoma,sarcomao Granulomataàsarcoid,tuberculosiso Latrogenicàsurgeryorirradiationo Headinjuryo Sheehan'ssyndrome(postpartumpituitaryhaemorrhageresultinginnecrosisof

thegland)o InfarctionorpituitaryapoplexyIdiopathic



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PanhypopituitarismØ Deficiencyofmost/allofthepituitaryhormonesØ Usuallyduetospace-occupyinglesion/destructionofpituitaryglandØ Hormoneproductionisoftenlostinthefollowingorder:

o Growthhormoneàdwarfisminchildren,insulinsensitivityinadultso Prolactinàfailureoflactationafterdeliveryo Gonadotrophinsàlossofsecondarysexualcharacteristics,secondary

amenorrhoeainwomen,lossoflibidoandinfertilityinmeno TSHàhypothyroidismo ACTHàhypoadrenalismandhyperpigmentation,withlossofsecondarysexual

hairduetodecreasedadrenalandrogenproduction Findings Descriptions&Significance PicturesGeneralinspection

• Patientmaybeofshortstatureàfailureofgrowthhormonesecretionbeforegrowthiscomplete)

• Lookforpallorofskinàduetoanaemia/occasionallyACTHdeficiencybecauseofthelossofitsmelanocyte-stimulatingactivity

• Lookforfine-wrinkledskinandlackofbodyhairàduetogonadotrophindeficiency

• Theremaybecompleteabsenceofsecondarysexualcharacteristicsifgonadotrophinfailureoccurredbeforepuberty

Face • Multipleskinwrinklesaroundtheeyesàcharacteristicofgonadotrophindeficiency

• Inspectforeheadforhypophysectomyscars

• Transfrontalscarswillbeapparentbutnottranssphenoidalscar(thisoperationisperformedthroughthebaseofnose,viaincisionundertheupperlip)

• Examinethevisualfieldsforanydefects,especiallybitemporalhemianopia(enlargingpituitarytumourmaycompressopticchiasm)



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Face(Continued)

• Examinefundiforopticatrophy(opticnervecompressionfromapituitarytumour)

• Assessthe3rd,4th,6thcranialnerves&firstdivisionof5thcranialnervesàmaybeaffectedbyextrapituitarytumourexpansionintocavernoussinus

• Feelthefacialhairoverthebeardedareainmenfornormalbeardgrowth(whichislostwithgonadotrophindeficiency)

Chest • Lookforskinpallor&decreaseinnipplepigmentation

• Inmen,decreasedbodyhair(axillaryandchest)maybepresent

• Inwomen,secondarybreastatrophymaybefound

Genital • Lossofpubichairoccursinbothsexes• Inmen,testicularatrophy

(characteristicallysmallandfirm)maybepresent

• Normal-sizedtestisisabout15to25mLinvolume



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AcromegalyØ Excessivesecretionofgrowthhormone,typicallyduetoeosinophilicpituitary

adenomaØ Growthhormonestimulatesliverandothertissuestoproducesomatomedins/

insulin-likegrowthfactor-1,whichinturnpromotegrowthØ Growthhormoneisalsoaproteinanabolichormoneexertingitseffectsatribosomal

level,anditisdiabetogenicasitexertsananti-insulineffectinmuscleandincreaseshepaticglucoserelease

Ø Gigantismàresultofgrowthhormonehypersecretionoccurringbeforepubertyandfusionofepiphyses

Ø Itresultsinmassiveskeletalaswellassoft-tissuegrowthØ Acromegalyoccurswhenthegrowthplateshavefusedàonlysofttissueandflat

boneenlargementarepossibleØ Beforepuberty(beforelongboneepiphysesfused)àproducesgigantismØ Afterpuberty(afterlongboneepiphysesfused)àcausesacromegalyØ GHstimulatesexcessiveàresponsibleforclinicalmanifestationsFindings Descriptions&Significance PicturesGeneralinspection

• Face&bodyhabitusmaybecharacteristic



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Hands • Lookatthehandsforwidespade-likeshapeàduetosofttissueandbonyenlargement

• Lookatthepalmsforincreasedsweating&warmthàduetoincreasedmetabolicrate

• Skinmayappearthickened• Changesofosteoarthritisinthehands

àduetoskeletalovergrowth• Examineformediannerve

entrapmentàduetosoft-tissueovergrowthincarpaltunnelarea

• Lookforsoft-tissueenlargementandcomplicationsarisingfromthis(tight-fittingringsorshoes,carpaltunnelsyndrome)

Face • Lookforlargesupraorbitalridgeàcausesfrontalbossing(thismayalsooccuroccasionallyinPaget'sdisease,rickets,achondroplasiaorhydrocephalus)

• Lookatthefaceforcoarseningoffeatures,thickgreasyskin,enlargementofnose

• Thelipsmaybethickened• Examineeyesforvisualfielddefects

àexpansionoftumourcancausepressureonopticchiasm,resultinginvisualfielddefects,especiallybitemporalhemianopia

• Lookinthefundiforopticatrophyàduetonervecompression

• Lookforpapilloedemaàduetoraisedintracranialpressurewithextensivetumour)

• Lookforpresenceofangioidstreaks(red,brownorgreystreaksthatare3-5timesthediameterofretinalveinandappeartoemanatefromopticdisc)àduetodegenerationandfibrosisofBruch'smembrane

• Lookforhypertensive/diabeticchangesinfundus



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Face(Continued)

• Ocularpalsiesmayoccurwithextensivepituitarytumour

• Lookinthemouthforenlargedtongue&theteeththemselvesmaybesplayedandseparated,withmalocclusionasthejawenlarges

• Lowerjawmaylooksquareandfirm• Whenthejaw/mandibleprotrudes

àprognathism

Neck • Thyroidmaybediffuselyenlarged/multinodular(allinternalorgansmayenlargeundertheinfluenceofgrowthhormone)

• Listentovoiceforhoarseness

Chest • Lookforcoarsebodyhair&gynaecomastia

• Examineheartforsignsofarrhythmias,cardiomegaly,congestivecardiacfailureàduetoischaemicheartdisease,hypertensionorcardiomyopathy

Back • Inspectforkyphosis



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8.AdrenalsExaminationTECHNIQUES AnatomyØ Smallpyramidalorganslyingimmediatelyabovethekidneysontheirposteromedial

surfaceØ Adrenalmedullaàpartofthesympatheticnervoussystemandsecretes

catecholaminesØ Adrenalcortexàsecretescortisol,mineralocorticoidsandandrogens

Cushing’ssyndromeØ Causedbyexcessexogenous/endogenouscorticosteroidexposureØ MostcasesareiatrogenicàduetosideeffectsofcorticosteroidtherapyØ ‘Endogenous’Cushing’sàusuallyresultsfromACTH-secretingpituitary

microadenomaØ Othercausesàprimaryadrenaltumour/‘ectopic’ACTHsecretionØ Cataboliceffectsofsteroidsàcausewidespreadtissuebreakdown(particularlyin

skin,muscleandbone)withcentralaccumulationofbodyfatØ Proximalmyopathy,fragilityfractures,spontaneouspurpura,skinthinningand

susceptibilitytoinfectionarecommonØ HyperthyroidismcanoccuràduetoexcesspituitaryTSHproductionØ ProlactinomasofpituitaryàcancausegalactorrheaØ PatientsmaybehypertensiveØ SteroidshavemultipleeffectsonbodyàduetostimulationofDNA-dependent

synthesisofselectmessengerribonucleicacids(RNAs)àleadstoformationofenzymes,whichaltercellfunctionàresultinincreasedproteincatabolismandgluconeogenesis

Ø Cushing'sdiseaseàspecificallypituitaryACTHoverproduction;Cushing'ssyndromeàduetoexcessivesteroidhormoneproductionfromanycause



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Sitting • Askpatienttositonthesideofbedandexamine

–

Face&neck • Lookforplethoraàoccursintheabsenceofpolycythaemia

• Thefacemayhavetypicalmoonshapeàduetofatdepositioninupperpart

• Inspectforacneandhirsutism• Lookfortelangiectasiae• Examinevisualfieldsforsignsof

pituitarytumour• Examinefundiforvisualfielddefects,

opticatrophy,papilloedema,cataracts&hypertensiveordiabeticchanges

• Lookforsupraclavicularfatpads

Abdomen • Laythepatientinbedononepillow• Examineabdomenforpurplestriaeà

duetoweakeninganddisruptionofcollagenfibresindermis,leadingtoexposureofvascularsubcutaneoustissues

• Thesearewider(1cm)thanthosewhogainedweightrapidlyforotherreasons

• Mayalsobepresentneartheaxillaeonupperarms/insideofthighs

• Palpateforadrenalmasses(rarelyalargeadrenalcarcinomawillbepalpableovertherenalarea)

• Palpateforhepatomegalyàduetofatdeposition/rarelytoadrenalcarcinomadeposits



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CausesofCushing'ssyndromeCauses Descriptions&Significance

ExogenousadministrationofexcesssteroidsorACTH(mostcommon)

• Steroids

Adrenalhyperplasia • SecondarytopituitaryACTHproduction(Cushing'sdisease)o Microadenomao Macroadenomao Pituitary-hypothalamicdysfunction

• SecondarytoACTH-producingtumoursàsmallcelllungcarcinoma

Adrenalneoplasia • Adenoma• Carcinoma(rare)



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Addison’sdiseaseØ Adrenocorticalhypofunctionwithreductioninsecretionofglucocorticoidsand

mineralocorticoidsØ UsuallysecondarytoautoimmunedestructionofadrenalcortexØ Symptomsareusuallynon-specificØ Weakness,musclecramps,nausea,vomiting,diarrheaorconstipationmayoccurFindings Descriptions&Significance PicturesGeneralinspection

• Lookforsignsofweightloss/cachexia

Skin • Examineentireskinsurfaceforabnormal/excessivepigmentationàmostprominentinsun-exposedareasorepitheliasubjecttotraumaorpressure(skincreases,buccalmucosaandrecentscars)

• Alsolookforpigmentationinpalmarcreases,elbows,gumsandbuccalmucosa,genitalareasandinscars

• Excesspigmentationàproducedbymelanocyte-stimulatinghormoneinprimaryadrenalinsufficiency

• Checkforvitiligo(localisedhypomelanosis)àoccursbecauseofcompensatoryACTHhypersecretioninprimaryhypoadrenalism(whenthereisadrenaldisease)asACTHhasmelanocyte-stimulatingactivity)



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9.GonadsExaminationTECHNIQUES Introduction:Ø Theseglandssecretesexhormones(oestrogenandtestosterone)inresponseto

gonadotrophin(FSHandLH)releasebypituitaryØ AlsocontainthegermcellsØ Klinefelter’ssyndrome(47XYY)àmostcommoncauseofprimaryhypogonadismin

menØ Diagnosismaybedelayeduntillaterlife,bywhichtimefeaturesofprolonged

testosteronedeficiencycanbeseenØ Lookforsoft,finelywrinkled,hairlessfacialskinandgynaecomastia&examinethe

genitalia(pubichairisoftenreduced/absent&testes<3mlinvolume)Ø HirsutismiscommoninwomenwithpolycysticovarysyndromeØ Virilisationàtemporalrecessionofscalphair,deepeningofvoice,breastatrophy,

increasedmusclebulkandclitoromegalyØ Ifpresentinwomenwithshorthistoryofseverehirsutismàsuggestspossible

testosterone-secretingtumourFemalegenitaliaexamination:Ø EnlargementofclitorisàexcessandrogensecretionØ Ambiguityofexternalgenitaliaàindicativeoffetalandrogenexcessinkaryotypic

femaleandoftestosteroneordihydrotestosteronedeficiencyorresistanceinmaleTesticularexamination:Ø Checktesticularvolumeandmeasurebycomparisonwithcalibratedovoids(Prader

orchidometer)Ø Prepubertaltesticularvolumeis<4ml;increasedvolumeimpliespubertal

gonadotrophinstimulationØ Onsetofthepubertalgrowthspurtinboysàtesticularvolumeof10ml;normal

adulttesticularvolumeà15to25mlØ Growthvelocityandgonadalchanges(testicularvolumeorbreaststage)are

concordant,anddiscordanceofpubertyproceedingaheadofgrowthàimpliesabnormalsourceofsexsteroid(e.g.androgen-secretingtumoursorcongenitaladrenalhyperplasia)

Ø Testicularatrophyàindicateshypogonadism,duetoprimarytesticularfailure,hypothalamopituitarydysfunctionorchronicliverdisease

Ø TumoursofLeydigcellsàusuallypalpable&shouldbesoughtingynaecomastiapatient



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Praderorchidometer

OTHERSTECHNIQUES&FINDINGS CarcinoidsyndromeØ Livermetastasesfrommid-gutcarcinoidtumourreleasevasoactivechemicalsinto

systemiccirculationàcauseflushing,diarrhoeaandbronchospasmØ Bending,exerciseorevenpalpationofenlargedlivermayinducetypicalskinflushingØ Permanentfacialtelangiectasiaoccursaftermanyyearsofcarcinoidflushing

______________________________THEEND_______________________________



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REFERENCES 1. OxfordClinicalSkills–OxfordCoreTexts2. BatesGuidetoPhysicalExaminationandHistoryTaking(InternationalEdition)3. TalleyandO’Connor-ClinicalExaminationASystematicGuidetoPhysicalDiagnosis4. MacLeod’sClinicalExamination5. Hutchison’sClinicalMethods6. Browse’sIntroductionToTheSymptomsAndSignsOfSurgicalDiseases7. Harrison’sPrinciplesofInternalMedicine8. Davidson’sPrinciplesandPracticeofMedicine9. Kumar&ClarksClinicalMedicine10. OtherjournalsandarticlesFOLLOWUS&LIKEUS____

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