clinical examination in endocrine disease
TRANSCRIPT
630 • ENDOCRINOLOGY
Hands
Palmar erythemaTremorAcromegalyCarpal tunnel syndrome
Skin
Hair distributionDry/greasyPigmentation/pallorBruisingVitiligoStriaeThickness
Pulse
Atrial fibrillationSinus tachycardiaBradycardia
Breasts
GalactorrhoeaGynaecomastia
Neck
Voice Hoarse, e.g. hypothyroid VirilisedThyroid gland (see opposite) Goitre Nodules
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Observation• Most examination in endocrinology is by observation• Astute observation can often yield ‘spot’ diagnosis of endocrine disorders• The emphasis of examination varies depending on which gland or hormone is thought to be involved
Body fat
Central obesity in Cushing’ssyndrome and growth hormonedeficiency
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Height and weight
Bones
Fragility fractures (e.g. ofvertebrae, neck of femur ordistal radius)
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Genitalia
VirilisationPubertal developmentTesticular volume
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Legs
Proximal myopathyMyxoedema
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Blood pressure
Hypertension in Cushing’sand Conn’s syndromes,phaeochromocytomaHypotension in adrenalinsufficiency
Eyes Graves’ disease (see opposite) Diplopia Visual field defect (see opposite)Hair Alopecia Frontal balding
Facial features Hypothyroid Hirsutism Acromegaly Cushing’s
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Prognathism inacromegaly
Acromegalic hands. Note softtissue enlargement causing‘spade-like’ changes
Pigmentation of creasesdue to high ACTH levelsin Addison’s disease
Vitiligo in organ-specificautoimmune disease
Multinodulargoitre
Pretibial myxoedemain Graves' disease
Head
Mental state Lethargy Depression Delirium Libido
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Clinical examination in endocrine disease
Endocrine disease causes cl inical
syndromes with symptoms and signs
involving many organ systems. The
emphasis of the clinical examination
depends on the gland or hormone that
is thought to be abnormal.
Diabetes mellitus (described in detail in
Ch. 20) and thyroid disease are the most
common endocrine disorders.
Clinical examination in endocrine disease • 631
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6 Examination of the visual fields by confrontation
• Sit opposite patient• You and patient cover oppositeeyes
• Bring red pin (or wiggling finger)slowly into view from extreme ofyour vision, as shown
• Ask patient to say ‘now’ when itcomes into view
• Continue to move pin into centreof vision and ask patient to tellyou if it disappears
• Repeat in each of four quadrants• Repeat in other eye
A bitemporal hemianopia is theclassical finding in pituitarymacroadenomas (p. 683)
6 Examination in Graves’ ophthalmopathy
• Inspect from front and side Periorbital oedema (Fig. 18.8) Conjunctival inflammation (chemosis) Corneal ulceration Proptosis (exophthalmos)* Lid retraction*
• Range of eye movements Lid lag on descending gaze* Diplopia on lateral gaze
• Pupillary reflexes Afferent defect (pupils constrict further on swinging light to unaffected eye, Box 25.22)
• Vision Visual acuity impaired Loss of colour vision Visual field defects
• Ophthalmoscopy Optic disc pallor Papilloedema
*Note position of eyelids relative to iris.
Normal
Proptosis
Right proptosis and afferent pupillary defect
Lidretraction
Normal
Normaldescent
Lid lagdescent
7 Examination of the thyroid gland
Diffuse firm goitre Hashimoto’s thyroiditis (p. 646)
Diffuse tender goitre Subacute thyroiditis (p. 646)
Abnormal findings
Diffuse soft goitre with bruit Graves’ disease (p. 643)
Multinodular goitre (p. 648) ± Retrosternal extension, tracheal compression
Solitary nodule (p. 642) Adenoma, cyst or carcinoma
Cervical lymphadenopathy Suggests carcinoma
• Inspect from front to side
• Palpate from behind Thyroid moves on swallowing Check if lower margin is palpable Cervical lymph nodes Tracheal deviation
• Auscultate for bruit Ask patient to hold breath If present, check for radiating murmur
• Percuss for retrosternal thyroid
• Consider systemic signs of thyroid dysfunction (Box 18.7) incl. tremor, palmar erythema, warm peripheries, tachycardia, lid lag
• Consider signs of Graves’ disease incl. ophthalmopathy, pretibial myxoedema
• Check for Pemberton’s sign, i.e. facial engorgement when arms raised above head
720 • DIABETES MELLITUS
Clinical examination of the patient with diabetes
Insets ( Acanthosis nigricans) From Lim E (ed.). Medicine and surgery: an integrated textbook. Edinburgh: Elsevier Ltd; 2007. ( Exudative maculopathy)
Courtesy of Dr A.W. Patrick and Dr I.W. Campbell.
Blood pressure
Skin
BullaePigmentationGranuloma annulareVitiligo
Axillae
Neck
Carotid pulseBruitsThyroid enlargement
Eyes (see opposite)
Visual acuityCataract/lens opacityFundoscopy
Insulin injection sites
(see opposite)
Hands
(see opposite)
Feet (see opposite)
InspectionPeripheral pulsesSensation
Abdomen
Hepatomegaly(fatty infiltration of liver)
Legs
Muscle-wastingSensory abnormalityHair lossTendon reflexes
Exudative maculopathy
Necrobiosis lipoidica
Charcot neuroarthropathy
Neuropathic foot ulcer
Head
XanthelasmaCranial nerve palsy/eyemovements/ptosis
Observation• Weight loss in insulin deficiency• Obesity in type 2 diabetes• Mucosal candidiasis• Dehydration– dry mouth, ↓tissue turgor• Air hunger– Kussmaul breathing in ketoacidosis
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Acanthosis nigricans
in insulin resistance
‘Prayer sign’
Clinical examination of the patient with diabetes • 721
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Diabetes can affect every system in the
body. In routine clinical practice, exam-
ination of the patient with diabetes is
focused on hands, blood pressure, axillae,
neck, eyes, insulin injection sites and feet.
1 Examination of the hands
Several abnormalities are more common in
diabetes:
• Limited joint mobility (‘cheiroarthropathy’)
causes painless stiffness. The inability to
extend (to 180°) the metacarpophalangeal
or interphalangeal joints of at least one
finger bilaterally can be demonstrated in
the ‘prayer sign’
• Dupuytren’s contracture (p. 1059) causes
nodules or thickening of the skin and
knuckle pads
• Carpal tunnel syndrome (p. 1139)
presents with wrist pain radiating into
the hand
• Trigger finger (flexor tenosynovitis) may
be present
• Muscle-wasting/sensory changes may be
present in peripheral sensorimotor
neuropathy, although this is more
common in the lower limbs
Background retinopathy. Courtesy of Dr
A.W. Patrick and Dr I.W. Campbell.
Proliferative retinopathy. Courtesy of Dr
A.W. Patrick and Dr I.W. Campbell.
7 Examination of the eyes
Visual acuity
• Check distance vision using Snellen chart
at 6 m
• Check near vision using standard reading
chart
• Note that visual acuity can alter reversibly
with acute hyperglycaemia due to osmotic
changes affecting the lens. Most patients
with retinopathy do not have altered
visual acuity, except after a vitreous
haemorrhage or in some cases of
maculopathy
Lens opacification
• Look for the red reflex using the
ophthalmoscope held 30 cm from
the eye
Fundal examination
• Either use a three-field retinal camera or
dilate pupils with a mydriatic (e.g.
tropicamide) and examine with an
ophthalmoscope in a darkened room
• Note features of diabetic retinopathy
(p. 1174), including photocoagulation
scars from previous laser treatment
8 Insulin injection sites
Main areas used
• Anterior abdominal wall
• Upper thighs/buttocks
• Upper outer arms
Inspection
• Bruising
• Subcutaneous fat deposition
(lipohypertrophy)
• Subcutaneous fat loss (lipoatrophy;
associated with injection of unpurified
animal insulins – now rare)
• Erythema, infection (rare)
Lipohypertrophy of the upper arm.
11 Examination of the feet
Inspection
• Look for evidence of callus formation on
weight-bearing areas, clawing of the toes
(in neuropathy), loss of the plantar arch,
discoloration of the skin (ischaemia),
localised infection and ulcers
• Deformity may be present, especially in
Charcot neuroarthropathy
• Fungal infection may affect skin between
toes, and nails
Circulation
• Peripheral pulses, skin temperature and
capillary refill may be abnormal
Sensation
• This is abnormal in stocking distribution in
typical peripheral sensorimotor neuropathy
• Testing light touch with monofilaments is
sufficient for risk assessment; test other
sensation modalities (vibration, pain,
proprioception) only when neuropathy is
being evaluated
Reflexes
• Ankle reflexes are lost in typical
sensorimotor neuropathy
• Test plantar and ankle reflexes
Monofilaments. The monofilament is
applied gently until slightly deformed at five
points on each foot. Callus should be
avoided as sensation is reduced. If the
patient feels fewer than 8 out of 10
touches, the risk of foot ulceration is
increased 5–10-fold.
346 • CLINICAL BIOCHEMISTRY AND METABOLIC MEDICINE
Clinical examination in biochemical and metabolic disorders
Many biochemical and metabolic disorders are clinically silent or present with non-specific manifestations, and are first detected by
laboratory testing. Several abnormalities can be picked up by history and physical examination, however, as summarised below.
Insets: (ankle oedema) From Huang H-W, Wong L-S, Lee C-H. Sarcoidosis with bilateral leg lymphedema as the initial presentation: a review of the
literature. Dermatologica Sinica 2016; 34:29–32; (raised jugular venous pressure) Newby D, Grubb N. Cardiology: an illustrated colour text. Edinburgh:
Churchill Livingstone, Elsevier Ltd; 2005; (cherry-red spots) Vieira de Rezende Pinto WB, Sgobbi de Souza PV, Pedroso JL, et al. Variable phenotype and
severity of sialidosis expressed in two siblings presenting with ataxia and macular cherry-red spots. J Clin Neurosci 2013; 20:1327–1328; (photosensitive
rash) Ferri FF. Ferri’s Color atlas and text of clinical medicine. Philadelphia: Saunders, Elsevier Inc.; 2009; courtesy of the Institute of Dermatology, London.
Hyperlipidaemia
Xanthelasma
Corneal arcus
Gangliosidosis
Cherry-red spot fundus
Porphyria
Photosensitive rash
Hyperlipidaemia
Tendon xanthoma
Eruptive xanthoma
Observation• General appearance• Skin turgor• Oedema• Rash• Eyes
Hypervolaemia
Raised jugular venouspressure
Ankle oedema
Hypovolaemia
Low blood pressure
Rapid pulse
Acute hypernatraemia
Extra heart soundsDizzinessDeliriumWeakness
Acute hyponatraemia
Cerebral oedemaVomitingSomnolenceSeizuresComa
Glycogen storage disease
Hepatomegaly
Abdominal pain
Extra heart sounds
Atheroma
Lung crepitations
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Clinical examination in biochemical and metabolic disorders • 347
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Assessment of volume status and electrolyte disturbances
Check blood pressure, pulse and jugular venous pressure Check for dry mouth
Check for sacral and ankle oedema Examine chest for pleuraleffusion
Examine abdomen forhepatomegaly and ascites
Check bloods Review results Check ECG Hypokalaemia Hyperkalaemia
Check skin turgor
Check for signs of hyperlipidaemia
Check skin and tendons for xanthomas Check eyes for arcus and xanthelasma
PeakedT wave
U wave
STdepression
692 • NUTRITIONAL FACTORS IN DISEASE
Insets (Scaphoid abdomen) From Chandra A, Quinones-Baldrich WJ. Chronic mesenteric ischemia: How to select patients for invasive treatment. Sem Vasc
Surg 2010; 23:21–28; (Koilonychia) Habif TP. Clinical Dermatology, 6th edn. Philadelphia: Saunders, Elsevier Inc.; 2016; (Gingivitis) Newman MG, Takei H,
Klokkevold PR, et al. Carranza’s Clinical Periodontology, 12th edn. Philadelphia: Saunders, Elsevier Inc.; 2015; (Corkscrew hairs) Bolognia JL, Jorizzo JL,
Schaffer JV, et al. Dermatology, 3rd edn. Philadelphia: Saunders, Elsevier Inc.; 2012.
Eyes
Sunken eyesPallorJaundiceBitot spots (↓vitamin A;see Fig. 19.12)
Hands
Muscle wasting (dorsal interossei,thenar eminences)Finger clubbingLeukonychia (low albumin)Koilonychia (iron deficiency)
Simple anthropometrics(see right)
Body mass indexTriceps skin fold thicknessWaist circumference
Legs
Pitting oedemaUlcers
Affect
FatigueDepressionDementia
Mouth
PallorAngular stomatitis (↓B12, folate,iron)Glossitis (↓B12, folate, iron)Gingivitis, bleeding gums(↓vitamin C; see Fig. 19.14)Poorly fitting dentures
Corkscrew hairs
Gingivitis
Koilonychia
Scaphoid abdomen
Clinical effects of short bowelsyndrome after multipleresection in Crohn’s disease
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Skin
Dry, flaky skin or dermatitis (seeFig. 19.13)Hair lossSpecific abnormalities: Petechiae, corkscrew hairs (↓vitamin C) Dermatitis of pellegra (↓niacin)
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Observation
Signs of weight loss: Prominent ribs Muscle wasting ↓Skin turgor
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Clinical examination in nutritional disorders
Clinical assessment and investigation of nutritional status • 693
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Clinical assessment and investigation of nutritional status
Important elements of the diet history
Ask about weight
• Current weight
• Weight 2 weeks, 1 month and 6 months
ago
• Assessment of degree of change
Ask about current food intake
• Quantity of food and if any change
• Quality of food taken
• Whether normal food is being eaten
• Avoidance of specific food types (e.g.
solids)
• Any nutritional supplements
• Reliance on supplements/tube feeding
• Any change in appetite or interest in
food
• Any taste disturbance
Ask about symptoms that interfere with eating
• Oral ulcers or oral pain
• Difficulties swallowing
• Nausea/vomiting
• Early satiety
• Alteration in bowel habit
• Abdominal (or other) pain
Ask about activity levels/performance status
• Normal activity
• Slightly reduced activity
• Inactive < 50% of the time
• Inactive most of the time
Under-nutrition can go unnoticed in
patients with multiple comorbidities. It is
vital to be aware of under-nutrition as a
potential reason for any acute medical
presentation or as a modifier of it. Early
nutritional assessment is crucial and a
dietary history provides useful information
(especially when taken by a dietitian). Points
to note include past medical and surgical
history (e.g. abdominal or intestinal surgery),
a drug history and a specific diet history.
Evidence of recent weight loss and muscle
wasting should be sought. Simple, validated
tools are available to screen patients for
nutritional problems. Body composition
reflects energy balance and is assessed
by clinical anthropomorphic measurements.
More sophisticated techniques may be used
to assess body composition or functional
capacity if required.
2 Body mass index (BMI)
BMIwt kg
ht m=
( )
( )2
Example: an adult of 70 kg with a height of
1.75 m has a BMI of 70/1.752 = 22.9 kg/m2
• BMI is a useful way of identifying under- or
over-nutrition but cannot discriminate
between lean body or muscle mass and fat
mass
• Fat mass is also subject to ethnic variation;
for the same BMI, Asians tend to have
more body fat than Europeans
• If height cannot be determined (e.g. in older
people or those unable to stand),
measurement of the femoral length or ‘knee
height’ is a good surrogate
Measurement of knee height.
2 Measures of body composition and nutritional status
Body composition
• Anthropometry (see below)
• Bioelectrical impedance
• Dual X-ray absorptiometry (DXA)
Muscle function and global
nutritional status
• Hand grip strength (dynamometer test)
– poor grip associated with increased
mortality
Obesity and fat distribution (android
vs gynoid)
• Waist:hip ratio (circumferences measured
midway between superior iliac crest and
lower border of rib cage, and at greater
trochanters, respectively)
Body fat content and muscle mass
• Triceps skinfold thickness (when combined
with mid-/upper arm circumference
estimates muscle mass)
Triceps skinfold thickness. Lean patients
6–12 mm; obese patients 40–50 mm.
Screening hospitalised patients for risk of malnutrition. Acute illnesses include decompensated liver disease, cancer cachexia or being kept ‘nil by
mouth’. Adapted from the British Association of Parenteral and Enteral Nutrition Malnutrition Universal Screening Tool (www.bapen.org.uk).
Weight loss score
Unplanned loss in 6 months
< 5%5 – 10%> 10%
= 0= 1= 2
BMI score
> 2018.5 – 20
< 18.5
= 0= 1= 2
Acute disease score
Acute illness with nonutritional intakefor 5 days = 2
Total = 1 – Medium riskTotal = 0 – Low risk Total ≥ 2 – High risk
Total score
• Routine clinical care• Repeat screen weekly
• Document dietary intake for 3 days• Repeat screen weekly
• Refer to dietitian/nutrition support team• Review plan weekly