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What are the three main steps in the thyroid exam ? (Neck exam)
General inspection; neck and other
How is the patient positioned for the thyroid exam ?
What is observed in general inspection in the thyroid exam ?
Face (special finger test - lid lag; exophthalmos - from above
What are the general steps in the neck exam for thyroidism ?
Inspect; palpate; percuss; Auscultate; Pembertons; (Comment on dress - heat intolerance)
What is observed during inspection in the thyroid examination ?
Scars; swelling; prominent veins and swallowing (a glass of water)
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
What is palpated from the front during the neck exam ?
What is percussed in the neck exam ?
What do we auscultate for in the neck exam ?
Thyroid bruit; carotid bruit
In the neck examination what comes under the category of other ?
What are Chvostek's and Trousseau's signs ?
When should Chvostek's and Trousseau's signes tested ?
What is Chvostek's sign ?
What is Trousseau's sign ?
How long can Troussseau's sign be tested for ?
What should be examined in the legs in the thyroid exam ?
What is seen in the ankle jerk in the thyroid exam ?
What is a typical stem for cushing's disease/syndrome ?
56 year old man has noted recent weight gain
What is the differenct between cushings syndrome and cushing's disease ?
Disease refers specifically to a pituitary dependant cause !
How is the patient exposed in the cushing's exam ?
Undressed to the underpants
What are the three examination positions for cushing's disease ?
Standing; sitting; lying
What is examined in the standing position of the cushing's exam ? (2)
General inspection; arms
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
What should be tested on the arms in the thyroid exam ? How ?
Purple striae; Proximal myopathy (squat)
How is the patient positioned after examining the arms in the cushing's exam ?
What is examined in the sitting position of the Cushing's exam ?
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
What is examined after the face and neck in the cushing's exam ?
What should be noted on the back examination ?
Interscapular fat pad; kyphoscoliosis; tenderness over the vertebrae (OP fracture)
After examining the back; what is tested in the cushing's exam; How ?
Legs; Squat (proximal myopathy); Striae (thighs); Bruising and oedema
Mental state is observed after examining the legs - what is noted ? (3)
Depression; Psychosis; Irritability
How is the patient positioned next ? What is examined first ?
Lying down -> abdomen
What should be noted in the abdomen in the cushing's exam ?
Striae; adrenal masses/scars; liver (tumour depots) pigmentation
What other laboratory tests should be considered (general tests) ? Why ?
Urine - glucose; FBE - polycythaemia neutrophillia eosinopoenia; UEC - hypokalaemia alkalosis from ectopic ACTH tumour
What are three screening tests for cushing's syndrome ?
Morning:evening cortisol (morning = 2x evening); 24hr urine cortisol (>3x normal); 1mg dexamethasone overnight test
What can cause no suppression in the overnight dexamethasone test ?
Cushing's syndrome (EtOH; elevated LFTs; depression; obesity)
Which definitive tests in cushings involve Dexamethasone ?
2mg over 2/7 (0.5mg Q6H for 48hrs); 8mg over 2/7 (2mg Q6H for 48hrs)
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
What hormone do the other two definitive tests involve ?
What are the two ACTH based definitive test ?
ACTH level - Usually elevated; but can be inappropriately abnormal; Petrosal ACTH sampling
What is considered diagnostic in petrosal sinus sampling ?
Central:peripheral ACTH >=2 before CRH or >=3 after CRH
What is usually required to diagnose Cushing's syndrome ?
2 definitive tests
What sort of tumours excrete ectopic ACTH ? (4)
SCLC; Carcinoid of the lung/thymus; Islet cell carcinoma; Ovarian ca
What should be noted in general inspection in the diabetes exam ?
Facial appearance - endocrine facies; Weight - obesit; Hydration and pigmentation
What is unusual about the order of progression of the diabetes exam ?
Start at the legs
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)
In inspecting the legs; what should be noted about the joints ?
What should be palpated in the legs ? (4)
Foot temp (small vessel vascular disease); Capillary return; Palpable pulses; Pitting oedema
What is auscultated in the leg ?
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)
What causes Charcot's foot ?
Loss of proprioception; Neuro trauma (less prop and sensation) -> microtrauma and poor fine control -> deformation
What are the clinical features of Charcot's foot ? (3)
Claw toes; high arch; increased thickness
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
Why do we check BP and pulse lying and standing in the diabetes exam ?
Where do we go after the arm in the diabetes exam ?
Go to the eyes
What is tested in the eyes first ?
CN II - visual acquity
What lens changes occur in diabetes
Cataracts; Rubeosis (new blood vessels over the iris)
What are the features of a diabetic CN III palsy ? Why ?
Pupil sparing (infarction affects inner fibres - eye movement; compression affects outer fibres - pupil)
Which other cranial nerves are tested in the diabetes exam ?
Always test CN III; IV and VI
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
What are some proliferative retinal changes in diabetes ? (4)
New vessels; vitrious heamorrhage; retinal detachment; laser spots
What do we check after the eyes in the diabetes examination ? (2)
Mouth - candida; Ears - Pseudomonas
Working down; what do we check after the neck in the diabetes examination ?
Palpate and auscultate carotid arteries
What do we check after the carotids in the diabetes examination ?
Look for signs of chest infection
What is examined after the chest in the diabetes examination ?
What do we check the abdomen for ?
Fatty liver; fat hypertropy at injection sites
What tests should be asked for ?
Urinalysis - glucose and protein
We should ask the examiners if we can ______ the patient !
How can autonomic neuropathy impact cardiac function ? (3)
Postural hypotension (>30/20 mmHg); loss of sinus arrhythmia; valsalva doesn't cause slowing of HR
What can diabetes do to the genitourinary system ? (3)
Erectile dysfunction; Urinary retention; incontinence
Name 2 other features of diabetic autonomic neuropathy !
Loss of sweating; nocternal diarrhoea (gastroparesis)
What is a typical stem for panhypopituitarism ?
35 year old male who has lost his libedo
What hormones are impacted when 60% of the pituitary is lost ?
GH FSH and LH
What hormones are impacted when 80% of the pituitary is lost ?
What hormones are impacted when 100% of the pituitary is lost ?
How is the patient positiioned for the panhypopituitary examination ?
Stand fully undressed;
What should be noted on noted on general inspection ?
Pale skin and lack of hair
What might a lack of GH and FSH/LH cause ?
Sort stature; no secondary sexual characteristics (if failure before puberty)
What do we look for fine wrinkles around the eyes and face ?
Characteristic of GH deficiency
Where do we examine for a hypophysectimy scar ?
Forehead near the inner canthus of the eye
What cranial nerves should be tested ? Why ?
CN II; III; IV and VI; Bitemporal hemianopia and fundi for optic atrophy
Which division of CN V is impacted in panhypopituitarism ? Why ?
V1 (Ophthalmic) for extension into the cavernous sinus
What should be felt over the CN V3 sensory region ?
Looking at the thorax next in the panhypopituitarism exam what should be noted ? (3)
Decreased body hear; pale skin; gynaecomastia
What are the genitalia inspected for ? (2)
Loss of pubic hair; Small testes (normal 15-25mL)
What should be checked on the arms first of all ? Why ?
BP lying and standing; Decreased ACTH
What is tested on the ankles ? Why ?
Pretibial myxoedema abscent (Graves); Slow reflexes due to hypothyroidsm
Which tumours most commonly cause pan hypopituitarism ?
Chromophobe adenomas (most common in males); Space occupying (Craniopharyngioma; metastatic carcinoma)
Name 3 other causes of panhypopituitarism ! (Other than tumour)
Iatrogenic (radiation; surgery); Trauma; Vascular (Sheehan's syndrome)
What should be noted in general inspection in acromegaly ?
Hands - spade like shape
What are Diya's 5 S's of acromegaly activity ?
Skin tags; sweating; sugar (glucosuria); SBP and Scottoma
What are two other indications of acromegaly activity ?
Enlarged goitre and increased shoe/ring size; headache
What is examined at the hands ?
Spade like hands; Osteoarthrits; Phelen's wrist flexion test
What do we test in the arm ?
Ulnar thickening at the elbow; Proximal myopathy
Where does the osteoarthritis associated with acromegaly tend to occur ?
Hands; shoulders; hips and knees
What is examined after the arm in acromegaly ? What for ? (3)
Axilla - Skin tags; Greasy skin; Acanthosis nigricans
What should be noted about the face in acromegaly ? (5)
Frontal bossing; macroglssia; Prognathism (lower jaw enlargement); Hirsutism; Hoarseness
What happens to the teeth in prograthism ?
Splaying of the teeth
What may be noticied on the skin of the face in acromegaly ?
Acne; hirsutism in females
How does the voice sound in acromegaly ?
Deep; husky and resonant
What are the eyes checked for in acromegaly ?
Visual fields (Bitemporal hemianopia); CN II-VI; Fundi
What are angioid streaks ?
Red/brown/grey streaks 3-5x the diameter of veins eminating from the optic disc
What the PASH causes of angioid streaks ?
Pagets; Acromegaly; Sickle cell; Hyperphosphataemia
What else should be observed in the fundi in the acromegaly exam ?
Optic atrophy; papilloedema; diabetic of hypertensive changes
What is examined after the fundi ?
Thyroid (diffuse enlargement; MNG)
What is examined after the thyroid ?
Cardiovascular (CCF); Abdomen (liver; spleen; kidney)
What should be noted in the lower limbs in the acromegaly examination ?
OA and pseudogout
What are common lower limb features of acromegaly ?
Large osteophytes and ligamentous laxity
Why look for evidence of foot drop in acromegaly ?
Entrapment of the common peroneal nerve
What foot thickening occurs in acromegaly ?
Look for heel pad thickening
What other pituitary hormone disorders should be looked for ?
Hypothyroidism; adrenocortical insufficiency
What test results should be asked about in acromegaly ?
Urine (glucosuria) and BP
What might the patient have as evidence of disease progression ?
What is a typical stub for Addisons disease ?
65 year old male with weakness anorexia and weight loss
What is Addisons disease ?
Chronic renal insufficiency
What are the common primary causes of Addisons disease ?
Autoimmune adrenal disease >80%
What are the two polyglandular syndromes associated with Addisons ?
T1: Addison's hypoparathyroidism; primary hypogonasism; T2: Addison's T2DM; Hashimotos; Graves; primary hypogonadism
Name some infective cause of Addisons ? (2)
TB and histoplasmosis
Name some infiltrative cause of Addisons ? (2)
Amyloidosis and sarcoidosis
When the patient is undressed; which areas are examined for pigmentation ?
Palmar creases; elbows; gums and buccal mucosa
What other autoimmune diseases cause pigmentation changes ?
What can happen to the earlobes in Addisons ?
Why is the BP checked in Addisons ?
To look for a postural drop
What are some screening tests for Addisons ?
What electrolyte disturbances are seen in Addisons ?
Hyponatraemia; hyperkalaemia; Hyperchloraemic acidosis; Hypercalcaemia
What happens to the FBE in Addison's ?
What are the three difinitive tests for Addison's ?
Short Synacthen (0.25mg IM); Long Synacthen (8hr infusion if short equivocal); Plasma ACTH response
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