2. What are the three main steps in the thyroid exam ? (Neck exam)
    General inspection; neck and other
  3. How is the patient positioned for the thyroid exam ?
  4. What is observed in general inspection in the thyroid exam ?
    Face (special finger test - lid lag; exophthalmos - from above
  5. What are the general steps in the neck exam for thyroidism ?
    Inspect; palpate; percuss; Auscultate; Pembertons; (Comment on dress - heat intolerance)
  6. What is observed during inspection in the thyroid examination ?
    Scars; swelling; prominent veins and swallowing (a glass of water)
  7. What is palpated from behind with the neck flexed (in the thyroid exam) ?
    Thyroid enlargement (note size; shape; consistency; borders and mobility); thyroid tenderness; thyroid thrills; cervical nodes
  8. What is palpated from the front during the neck exam ?
  9. What is percussed in the neck exam ?
  10. What do we auscultate for in the neck exam ?
    Thyroid bruit; carotid bruit
  11. In the neck examination what comes under the category of other ?
  12. What are Chvostek's and Trousseau's signs ?
  13. When should Chvostek's and Trousseau's signes tested ?
  14. What is Chvostek's sign ?
  15. What is Trousseau's sign ?
  16. How long can Troussseau's sign be tested for ?
    Two minutes
  17. What should be examined in the legs in the thyroid exam ?
  18. What is seen in the ankle jerk in the thyroid exam ?
  20. What is a typical stem for cushing's disease/syndrome ?
    56 year old man has noted recent weight gain
  21. What is the differenct between cushings syndrome and cushing's disease ?
    Disease refers specifically to a pituitary dependant cause !
  22. How is the patient exposed in the cushing's exam ?
    Undressed to the underpants
  23. What are the three examination positions for cushing's disease ?
    Standing; sitting; lying
  24. What is examined in the standing position of the cushing's exam ? (2)
    General inspection; arms
  25. What should be noted on general examination in the Cushing's exam ?
    Look from front sides and behind; central adiposity with peripheral sparing; skin bruising; atrophy and pigmentation of extensor areas; poor wound healing
  26. What should be tested on the arms in the thyroid exam ? How ?
    Purple striae; Proximal myopathy (squat)
  27. How is the patient positioned after examining the arms in the cushing's exam ?
  28. What is examined in the sitting position of the Cushing's exam ?
  29. What should be noted in the face in the cushing's exam ?
    Skin (plethora; hirstutism; ance; telengectasia); Moon facies; Eyes (visual fields - fundi (HTN DM Papilloedema); Mouth thrush; Neck - supraclavicular fat pads; acanthosis nigricans
  30. What is examined after the face and neck in the cushing's exam ?
  31. What should be noted on the back examination ?
    Interscapular fat pad; kyphoscoliosis; tenderness over the vertebrae (OP fracture)
  32. After examining the back; what is tested in the cushing's exam; How ?
    Legs; Squat (proximal myopathy); Striae (thighs); Bruising and oedema
  33. Mental state is observed after examining the legs - what is noted ? (3)
    Depression; Psychosis; Irritability
  34. How is the patient positioned next ? What is examined first ?
    Lying down -> abdomen
  35. What should be noted in the abdomen in the cushing's exam ?
    Striae; adrenal masses/scars; liver (tumour depots) pigmentation
  36. What other laboratory tests should be considered (general tests) ? Why ?
    Urine - glucose; FBE - polycythaemia neutrophillia eosinopoenia; UEC - hypokalaemia alkalosis from ectopic ACTH tumour
  37. What are three screening tests for cushing's syndrome ?
    Morning:evening cortisol (morning = 2x evening); 24hr urine cortisol (>3x normal); 1mg dexamethasone overnight test
  38. What can cause no suppression in the overnight dexamethasone test ?
    Cushing's syndrome (EtOH; elevated LFTs; depression; obesity)
  39. Which definitive tests in cushings involve Dexamethasone ?
    2mg over 2/7 (0.5mg Q6H for 48hrs); 8mg over 2/7 (2mg Q6H for 48hrs)
  40. What are the two definitive tests used in dexamethasone testing ?
    2mg test - no suppression in cushings but suppression in obese/depressed; 8mg suppression in Cushings but not in adrenal tumour or ectopic ACTH
  41. What hormone do the other two definitive tests involve ?
  42. What are the two ACTH based definitive test ?
    ACTH level - Usually elevated; but can be inappropriately abnormal; Petrosal ACTH sampling
  43. What is considered diagnostic in petrosal sinus sampling ?
    Central:peripheral ACTH >=2 before CRH or >=3 after CRH
  44. What is usually required to diagnose Cushing's syndrome ?
    2 definitive tests
  45. What sort of tumours excrete ectopic ACTH ? (4)
    SCLC; Carcinoid of the lung/thymus; Islet cell carcinoma; Ovarian ca
  47. What should be noted in general inspection in the diabetes exam ?
    Facial appearance - endocrine facies; Weight - obesit; Hydration and pigmentation
  48. What is unusual about the order of progression of the diabetes exam ?
    Start at the legs
  49. What should be noted about the skin in the leg exam ?
    Neurobiosis (central yello scar with the surrounding red margin); hair loss; infection; ulceration; injection sites; quad wasting (femoral nerve mononeuritis)
  50. In inspecting the legs; what should be noted about the joints ?
    Charcot's joints
  51. What should be palpated in the legs ? (4)
    Foot temp (small vessel vascular disease); Capillary return; Palpable pulses; Pitting oedema
  52. What is auscultated in the leg ?
    Femoral artery
  53. What neurological assessment should be done in the leg (in the diabetes exam) ?
    Proximal muscle power; Reflexes; Peripheral neuropathy; Dorsal column loss (diabetic pseudotabes - vibration and proprioception)
  54. What causes Charcot's foot ?
    Loss of proprioception; Neuro trauma (less prop and sensation) -> microtrauma and poor fine control -> deformation
  55. What are the clinical features of Charcot's foot ? (3)
    Claw toes; high arch; increased thickness
  56. What do we examine after the lower limg in the diabetes exam ? What do we look for ?
    Arms; Injection sites; skin lesions; candida of the nails
  57. Why do we check BP and pulse lying and standing in the diabetes exam ?
    Autonomic neuropathy
  58. Where do we go after the arm in the diabetes exam ?
    Go to the eyes
  59. What is tested in the eyes first ?
    CN II - visual acquity
  60. What lens changes occur in diabetes
    Cataracts; Rubeosis (new blood vessels over the iris)
  61. What are the features of a diabetic CN III palsy ? Why ?
    Pupil sparing (infarction affects inner fibres - eye movement; compression affects outer fibres - pupil)
  62. Which other cranial nerves are tested in the diabetes exam ?
    Always test CN III; IV and VI
  63. What are some non-proliferative retinal changes in diabetes ? (4)
    Hhge (dot - inner retina; blot - superficial layers); hard exudate (straight edges from capiliaries); soft exudate (cotton wool spot) microinfarcts; microaneurysms
  64. What are some proliferative retinal changes in diabetes ? (4)
    New vessels; vitrious heamorrhage; retinal detachment; laser spots
  65. What do we check after the eyes in the diabetes examination ? (2)
    Mouth - candida; Ears - Pseudomonas
  66. Working down; what do we check after the neck in the diabetes examination ?
    Palpate and auscultate carotid arteries
  67. What do we check after the carotids in the diabetes examination ?
    Look for signs of chest infection
  68. What is examined after the chest in the diabetes examination ?
  69. What do we check the abdomen for ?
    Fatty liver; fat hypertropy at injection sites
  70. What tests should be asked for ?
    Urinalysis - glucose and protein
  71. We should ask the examiners if we can ______ the patient !
  72. How can autonomic neuropathy impact cardiac function ? (3)
    Postural hypotension (>30/20 mmHg); loss of sinus arrhythmia; valsalva doesn't cause slowing of HR
  73. What can diabetes do to the genitourinary system ? (3)
    Erectile dysfunction; Urinary retention; incontinence
  74. Name 2 other features of diabetic autonomic neuropathy !
    Loss of sweating; nocternal diarrhoea (gastroparesis)
  76. What is a typical stem for panhypopituitarism ?
    35 year old male who has lost his libedo
  77. What hormones are impacted when 60% of the pituitary is lost ?
    GH FSH and LH
  78. What hormones are impacted when 80% of the pituitary is lost ?
  79. What hormones are impacted when 100% of the pituitary is lost ?
  80. How is the patient positiioned for the panhypopituitary examination ?
    Stand fully undressed;
  81. What should be noted on noted on general inspection ?
    Pale skin and lack of hair
  82. What might a lack of GH and FSH/LH cause ?
    Sort stature; no secondary sexual characteristics (if failure before puberty)
  83. What do we look for fine wrinkles around the eyes and face ?
    Characteristic of GH deficiency
  84. Where do we examine for a hypophysectimy scar ?
    Forehead near the inner canthus of the eye
  85. What cranial nerves should be tested ? Why ?
    CN II; III; IV and VI; Bitemporal hemianopia and fundi for optic atrophy
  86. Which division of CN V is impacted in panhypopituitarism ? Why ?
    V1 (Ophthalmic) for extension into the cavernous sinus
  87. What should be felt over the CN V3 sensory region ?
    Facial hair
  88. Looking at the thorax next in the panhypopituitarism exam what should be noted ? (3)
    Decreased body hear; pale skin; gynaecomastia
  89. What are the genitalia inspected for ? (2)
    Loss of pubic hair; Small testes (normal 15-25mL)
  90. What should be checked on the arms first of all ? Why ?
    BP lying and standing; Decreased ACTH
  91. What is tested on the ankles ? Why ?
    Pretibial myxoedema abscent (Graves); Slow reflexes due to hypothyroidsm
  92. Which tumours most commonly cause pan hypopituitarism ?
    Chromophobe adenomas (most common in males); Space occupying (Craniopharyngioma; metastatic carcinoma)
  93. Name 3 other causes of panhypopituitarism ! (Other than tumour)
    Iatrogenic (radiation; surgery); Trauma; Vascular (Sheehan's syndrome)
  95. What should be noted in general inspection in acromegaly ?
    Hands - spade like shape
  96. What are Diya's 5 S's of acromegaly activity ?
    Skin tags; sweating; sugar (glucosuria); SBP and Scottoma
  97. What are two other indications of acromegaly activity ?
    Enlarged goitre and increased shoe/ring size; headache
  98. What is examined at the hands ?
    Spade like hands; Osteoarthrits; Phelen's wrist flexion test
  99. What do we test in the arm ?
    Ulnar thickening at the elbow; Proximal myopathy
  100. Where does the osteoarthritis associated with acromegaly tend to occur ?
    Hands; shoulders; hips and knees
  101. What is examined after the arm in acromegaly ? What for ? (3)
    Axilla - Skin tags; Greasy skin; Acanthosis nigricans
  102. What should be noted about the face in acromegaly ? (5)
    Frontal bossing; macroglssia; Prognathism (lower jaw enlargement); Hirsutism; Hoarseness
  103. What happens to the teeth in prograthism ?
    Splaying of the teeth
  104. What may be noticied on the skin of the face in acromegaly ?
    Acne; hirsutism in females
  105. How does the voice sound in acromegaly ?
    Deep; husky and resonant
  106. What are the eyes checked for in acromegaly ?
    Visual fields (Bitemporal hemianopia); CN II-VI; Fundi
  107. What are angioid streaks ?
    Red/brown/grey streaks 3-5x the diameter of veins eminating from the optic disc
  108. What the PASH causes of angioid streaks ?
    Pagets; Acromegaly; Sickle cell; Hyperphosphataemia
  109. What else should be observed in the fundi in the acromegaly exam ?
    Optic atrophy; papilloedema; diabetic of hypertensive changes
  110. What is examined after the fundi ?
    Thyroid (diffuse enlargement; MNG)
  111. What is examined after the thyroid ?
    Cardiovascular (CCF); Abdomen (liver; spleen; kidney)
  112. What should be noted in the lower limbs in the acromegaly examination ?
    OA and pseudogout
  113. What are common lower limb features of acromegaly ?
    Large osteophytes and ligamentous laxity
  114. Why look for evidence of foot drop in acromegaly ?
    Entrapment of the common peroneal nerve
  115. What foot thickening occurs in acromegaly ?
    Look for heel pad thickening
  116. What other pituitary hormone disorders should be looked for ?
    Hypothyroidism; adrenocortical insufficiency
  117. What test results should be asked about in acromegaly ?
    Urine (glucosuria) and BP
  118. What might the patient have as evidence of disease progression ?
    Serial photographs
  120. What is a typical stub for Addisons disease ?
    65 year old male with weakness anorexia and weight loss
  121. What is Addisons disease ?
    Chronic renal insufficiency
  122. What are the common primary causes of Addisons disease ?
    Autoimmune adrenal disease >80%
  123. What are the two polyglandular syndromes associated with Addisons ?
    T1: Addison's hypoparathyroidism; primary hypogonasism; T2: Addison's T2DM; Hashimotos; Graves; primary hypogonadism
  124. Name some infective cause of Addisons ? (2)
    TB and histoplasmosis
  125. Name some infiltrative cause of Addisons ? (2)
    Amyloidosis and sarcoidosis
  126. When the patient is undressed; which areas are examined for pigmentation ?
    Palmar creases; elbows; gums and buccal mucosa
  127. What other autoimmune diseases cause pigmentation changes ?
  128. What can happen to the earlobes in Addisons ?
  129. Why is the BP checked in Addisons ?
    To look for a postural drop
  130. What are some screening tests for Addisons ?
  131. What electrolyte disturbances are seen in Addisons ?
    Hyponatraemia; hyperkalaemia; Hyperchloraemic acidosis; Hypercalcaemia
  132. What happens to the FBE in Addison's ?
    Lymphocytosis; Eosinophilia
  133. What are the three difinitive tests for Addison's ?
    Short Synacthen (0.25mg IM); Long Synacthen (8hr infusion if short equivocal); Plasma ACTH response
Card Set
RACP endo cards