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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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Findings Descriptions&Significance Pictures
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
Findings Descriptions&Significance Pictures
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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Findings Descriptions&Significance Pictures
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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Findings Descriptions&Significance Pictures
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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Findings Descriptions&Significance Pictures
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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Findings Descriptions&Significance Pictures
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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Findings Descriptions&Significance Pictures
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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