Endocrine OSCE (2) PDF

# Clinical Internal Medicine Endocrine - Dr. Yakout A.R.J ## Examine Thyroid Gland (Hyperthyroidism) ### Technique - Greet patient and stand on his right side. - Explain to patient what you are going to do. - Ask and assist patient to uncover his neck - Stand behind patient. - Start palpation wit...

# Clinical Internal Medicine Endocrine - Dr. Yakout A.R.J ## Examine Thyroid Gland (Hyperthyroidism) ### Technique - Greet patient and stand on his right side. - Explain to patient what you are going to do. - Ask and assist patient to uncover his neck - Stand behind patient. - Start palpation with patient's neck mildly flexed. ### Comment **A. Inspection** - Butterfly shaped swelling or Swelling present in lower part of anterior compartment of neck (around Cricoid cartilage). - Mobile with deglutition (swallowing). - Not moved with protrusion of tongue. - To exclude Thyroglossal cyst. **B. Palpation** - **Size** → 3 x 5 cm as example. - **Surface** → smooth. - **Tenderness** or not. - **Consistency** → firm. - Soft → grave's disease. - Nodular → multi - nodular & solitary toxic nodule. - Hard → malignancy, gamma syphilis, riedel's thyroiditis. - **Thrill** or not → indicate hyper vascularity of gland in graves. - **Carotid pulsation** → felt. - **Isthmus** → no retrosternal extension (I can get below lower of isthmus). - **Lymph nodes (LNs)** → Submental, submandibular, pre - auricular, Pos - auricular, Occipital, upper cervical, middle cervical, lower cervical, supra - clavicular. **C. Percussion** - Over mamubrium of sternum. - **Resonant** → normal. - **Dullness** → retrosternal extension. **D. Auscultation** - Indicate hyper vascularity of gland - **Systolic murmur (thyroid bruit)** ### Important OSCE Questions - Enlarged supraclavicular L.Ns called Virchow L.Ns and occur du to malignancy in GIT. - Enlarged cervical L.Ns in thyroid case due to: - Reticulo - endothelial hyperplasia (REH) in grave's - metastatic thyroid carcinoma. - First investigation you are going done in this case → T3, T4, TSH - Ophthalmic signs of grave's disease: - Staring look (lid retraction): Appearance of upper rim of sclera - Lid Lag - Lack of convergence - Exophthalmos (symmetrical) tested by: - Looking tangentially from behind the patient's head at surface of cornea. - Rim of sclera below cornea. - Put your finger vertically over orbit after asking the patient to close his eyes. - Using exophthalmometer (Exophthalmos > 21 mm). - Conjunctival chemosis (edema). - Peri - orbital edema. - Ophthalmoplegia + fine tremors in eyelids. - Features only occurs in Grave's disease - **Eye signs (Exophthalmos)** - **Pretibial myxedema** (due to deposition of mucin like material → thick skin) - Thyroid acropathy (finger clubbing) - Diffuse goiter. - Signs prove retrosternal goiter - Dull manubrium on percussion. - I can't get below the isthmus (unable to palpate lower border). - Dilated veins over sternum. - Pemberton's sign: raising of arms or hyperextension of neck lead to congested neck veins and flushing of neck. - Kocher's sign: Stridor on pushing one lobe to other side. - **Causes of goiter (enlargement of thyroid gland and increase vascularity to gland):** - **Euthyroid goiter** - Puberty - Pregnancy - **Hyperthyroidism with goiter** - Grave's disease - Toxic multi nodular goiter - Toxic solitary nodule - Dequervain's thyroiditis (transient) - **Hypothyroidism with goiter** - Hashimoto thyroiditis - Endemic goiter (Iodine deficiency) - Dyshormonogenesis - Riedel's thyroiditis - **Causes of hypothyroidism without goiter:** - autoimmune atrophic thyroiditis. - Surgical removal of thyroid gland. - 2ry hypothyroidism. - Most common cause of hypothyroidism → Hashimoto thyroiditis - What is meant by pretibial myxedema? - Symmetric raised non - pitting edema. - Site: anterior surface of tibia. - well demarcated oval violaceous (dusky red) color. - **Types of ophthalmopathy:** - **Mechanical** (cellular infiltration) → exophthalmos (occur only in Grave's disease). - **Spastic** (sympathetic over activity) → lid lag, lid retraction (occur in all causes). - **Malignant** exophthalmos (associated with opthalmoplegia). - Drug that cause hyperthyroidism → Amiodarone - Treatment of Pregnant female with hyperthyroidism - Drug of choice → Thiouracil. - Surgery done only in 2nd trimester. - Radioactive iodine → contraindicated. - Subclinical hypothyroidism: - Normal T3, T4. - Increase TSH. - Asymptomatic. - One reliable investigation to differentiate Grave's from thyroiditis? - Radio active iodine - Active uptake - Grave disease → Increase - Thyroiditis → Decrease - Best method for follow up of hyperthyroidism: - In Iry hyperthyroidism → TSH (as it the last one to be corrected) - In 2ry hyperthyroidism → Free T4 (as it is already high) - **Causes of painful goiter:** - Thyroiditis (Dequervian, Hashimoto). - Bleeding into cyst. - Thyroid tumor. - How to differentiate between 1ry and 2ry hyperthyroidism? - TSH - Iry → Decrease - 2ry → Increase - T3, T4 - Iry → Increase - 2ry → Increase - **Causes of pallor in hypothyroidism** - Anemia - Hyperlipidemia - Mucopolysaccharides deposition - Hypercalcemia - In hypothyroidism in female - **Menorrhagia** in 1ry hypothyroidism as thyroxin is important for uterine contraction. - **Amenorrhea** in 2ry hypothyroidism. - **Gynecomastia** in hypothyroidism. Why? - due to increase prolactin as decrease thyroxin lead to increase TRH and increase prolactin - **Complications of hypothyroidism:** - Ischemic heart disease (commonest). - Myxedema madness. - Myxedema coma. - Most common cause of hypothyroidism → Hashimoto thyroiditis. - Early skin sign in hypothyroidism → puffy dorsum of hand, feet and face. - **Causes of puffiness of face:** - Hypothyroidism. - Nephrotic syndrome. - Angioneurotic edema. - SVC obstruction. - Why edema in hypothyroidism is non - pitting? - due to mucopolysaccharides deposition. - Cause of yellow color in hypothyroidism → increase Beta carotene which is not converted to vitamin A. - What us subclinical hypothyroidism? - Discussed before. ## Examine Acral Parts (in Acromegaly) - Face, Hand, Foot. ### General - Greet the patient and stood on his right side. - Explain the procedure to the patient. ### Examination of the Face - **Lower jaw** → Protruded (Prognathism). - **Teeth** → separation of teeth (Diastema). - **Supra - orbital ridge** → Prominent. - **Zygoma and zygomatic arch** → Prominent. - **Tongue** → Enlarged (Macroglossia). ### Examination of the Hands - **Size** → enlarged. - **Bulk of soft tissues** → Increased. - **Fingers** → Broad. - **Skin** → thickened, sweaty, greasy - **Increase ring size**. - **Doughy sensation** when shaking hands of patient. - **Abnormal sensation** → Carpal tunnel syndrome (Tested by Prayer test, reversed prayer test, Tinel test, Phalen test) ### Examination of the Feet - **Length** → increase. - **Width** → increase. - **Soft tissue** → enlarged. - **Soft tissue of heel** → increased. - **Skin** → thickened, sweaty, greasy - **Increase shoe size**. ### Important OSCE Questions - Diastema → separation of teeth. - Heel pad thickness - Normal → 22 mm - In acromegalic male → > 27 mm - In acromegalic female → > 25 mm. - Enlarged lips is called → macrochilia. - Enlarged tongue is called → Macroglossia. - Prominent supra - orbital ridge. Why? - due to enlargement of frontal sinuses. - Carpal tunnel syndrome → Compression of median nerve - Tarsal tunnel syndrome → Compression of posterior tibial nerve - Headache in acromegaly. Why? - due to systemic HTN & increase ICP. - **Hypertension and hypotension causes in acromegaly.** - **Hypertension causes:** - Hypercalcemia - Increase thickness of endothelial muscles of blood vessels. - Increase sensitivity of catecholamines. - **Hypotension causes:** - Heart failure. - Pituitary apoplexy. - 2ry hypoadrenalism. - **Complications = Causes of death in acromegaly.** - Pituitary apoplexy - Heart failure - HTN - severe hemorrhage - Degenerative vascular diseases - D.M - Hypopituitarism. - **Signs of activity in acromegaly:** - **Clinical** - Greasy sweaty skin - Blurred vision - Increase width of bones - Increase libido. - **Laboratory:** - Increase hydroxyl proline in urine - Increase IGF - 1 - Increase GH - Hypercalcemia - Hypercalcuria - Increase PO4. - **Radiological:** - Progressive increase in bone size. - Increase heel pad thickness > 27 mm. - Ballooning of sella turcica. - **Hyperglycemia and hyperinsulinemia in Acromegaly. Why?** - **Hyperglycemia** - As Growth hormone stimulate gluconeogenesis. - **Hyperinsulinemia** - As GH inhibit sensitivity of receptors to insulin lead to insulin resistance. - Ca renal stones in acromegaly. Why? - As GH enhance intestinal absorption of Ca → hypercalcemia → hypercalcuria → renal stones. - **Investigation of choice to diagnose acromegaly → IGF - 1 then glucose suppression test** - **Treatment of choice of acromegaly → Surgical hypophysectomy via trans - sphenoidal or trans - frontal approach** - **Pituitary gland cell that secrete GH → Acidophil by L.M or Somatotrophs by E.M** - **Hypertrichosis & Hirsutism .. define** - **Hypertrichosis** - Excessive normal hair occur in constitutional and - **Hirsutism** - abnormal hair in female occur in PCOS. - Most common cancer associated with acromegaly → cancer color. - Acanthosis nigricans → watery pigmentation in body folds occur in acromegaly due to insulin resistance. - **Causes of neuropathy in acromegaly.** - Carpal tunnel syndrome - Peripheral neuropathy - Spinal cord or nerve root compression from bony overgrowth. - **First investigation in this case → IGF-1, GH, Glucose suppression test** - **What are endocrinal manifestations associated with acromegaly?** - Hypopituitarism - D.M - Gynecomastia - Galactorrhea - Pigmentation - Goiter and hypothyroidism. - **Neurological manifestations associated with acromegaly** - Peripheral neuropathy → glove, stock hypothesis - Paresthesia in hands and feet due to tunnel syndrome, diabetic neuropathy - Pressure manifestation → optic atrophy, bitemporal hemianopia. ## Examine Short Stature ### Technique - Bare foot with feet flat on floor → no shoes, no socks. - Standing with his occiput, shoulder, buttocks, heel touch wall. - Knee straight. - Head straight → nothing on head (looking forward in Frankfort plane → outer canthus in line with external auditory meatus). - Measure Height → from top of head to bottom of foot. - Measure span → distance from tip of middle finger to the other one when arms are fully outstretched. - Measure upper body segment → from top of head to upper border of symphysis pubis - Measure lower body segment → from upper border of symphysis pubis to foot ### Comment - **Height** - Average = normal - Short stature - Tall stature - **Proportionality** - Proportionate (upper segment = lower segment && Span = Height) - Disproportionate (infantile U/L segment ratio → 1.7: 1) ### Important OSCE Questions - **Causes of short stature:** - **Endocrinal** - hypothyroidism - GH deficiency - precocious puberty - untreated D.M - untreated D.I - Vitamin D disorders - Juvenile Cushing syndrome - **Non - endocrinal** - Malnutrition - Chronic illness - Genetic - Constitutional - Achondroplasia - **Causes of Tall stature** - hypogonadism - Marfan syndrome - **Causes of Disproportionate short stature** - hypothyroidism - Achondroplasia - Precocious puberty - **Causes of proportionate short stature** - GH deficiency - Genetic short stature - Constitutional short stature - **Normal measurement in adult:** - total height: Span = 1: 1 - Upper body segment: lower body segment = 1:1 (proportionate measurement) - **Define short stature?** - decrease height > 2 standard deviation below 3rd percentile. - **Causes of short stature with delayed puberty:** - constitutional short stature - Chromosomal short stature - Panhypopituitarism - **Drugs cause short staure** - Corticosteroids (for treatment of asthma) - Dextroamphetamine (for hyperkinetic child) - **Factors affecting growth:** - **Prenatal causes:** - **Endocrinal factors** - Insulin & IGF-1 (very important for intrauterine growth) - Growth hormone (not important) - Thyroid hormone (important to mental growth but not important to physical growth) - **Maternal & Uterine factors.** - chronic systemic diseases - Intrauterine infections - Drugs → Phenytoin - Viruses → CMV, HIV - Alcohol - Smoking - **Chromosomal defects** - Turner syndrome - Down syndrome - **Postnatal causes:** - **Endocrinal factors** - Growth hormone (very important) - Sex hormones (Androgen, estrogen) → no effect before puberty - Thyroid hormone → important in bone matrix and ossification - **Genetic factors** - **Socio-economic factors** - malnutrition, bad hygiene - **Nutritional factors** → PEM, Zinc deficiency - **Chronic systemic disease** - **Psychological** - **Effect of glucocorticoids on growth** - decrease glucocorticoids → Addison → no effect on growth - Increase glucocorticoids → Cushing → Short stature - Impairs growth hormone by pituitary gland - Compete with GH in liver on IGF - 1 secretion - **Direct effect on bone matrix** - **Zinc is very important for action of growth hormone.** - **How to assess the growth?** - Height - Growth velocity (increase Ht by 4.5 cm per year) - Skeletal age (bone age) using x - ray on knee, wrist - Body proportionate - Sexual measurement by Tanner staging of puberty - Mental development (IQ assessment, achievement in school) - **Difference between constitutional and genetic short stature** - **Constitutional short stature** - Normal variation - No family history - Constitutional delay of puberty - Very thin, moderately short. - Delay closure of epiphysis (bone age < chronological age). - No endocrinal or organic manifestations. - **Genetic short stature** - It is a disease - Normal puberty - No thin, too short. - No delay of closure (bone age = chronological age) - May be associated with endocrin or organic manifestations - **List syndromes associated with short stature:** - **Silver Russel syndrome** - short stature - loss of subcutaneous fat - Asymmetry - **Turner syndrome** - short stature - female 45 X0 - neck webbing - Hypogonadism - Left sided cardiac lesion - **Noonan syndrome** - No mental retardation - Short stature - male 46 XY - neck webbing - Normal gonads - Right sided cardiac lesion - **Prader Willi syndrome** - Mental retardation - Short stature - defect in chromosome 15 - Obesity - Undescended testis - Hypotonia - **Laurance Moon Biedel Syndrome** - Short stature - Mental retardation - Hypogonadism - Obesity - Retinitis pigmentosa - Polydactly - **Down syndrome** - Short stature - Trisomy 21 - Mental retardation - Heart malformation - **Enumerate diseases diagnosed from face** - hypothyroidism - Turner syndrome - Down syndrome - Thalassemia - **How to treat pituitary infantilism?** - Give Growth hormone 1st then give Gonadotrophin hormone 2nd to avoid premature closure of epiphyses - **Types of growth** - Physical: weight, height - Mental: Corresponding chronological age - Sexual: Sexual characters - **Stimulation tests for Growth hormone** - Exercise: 20 minutes - Sleep: 2 hrs - Clonidine (orally): hypotension - L - dopa orally - Arginine infusion - **Special notes on causes of short stature** - **IUGR** - حيفضل طول عمره قصير - Intra uterine growth retardation - Small gestation age - Catch up growth after 1st 2 years - **SGA** - moon face - **Cushing** - Doll - like face - **GH deficiency** - Doll - like face - **Genetic short stature** - Short as young, short as adult - **Constitutional short stature** - Short as young, normal as adult - **Precocious puberty** - Tall as young, short as adult - axillary and pubic hair appear < 8 years in female and < 9 years in male - **Investigations of short stature** - **Laboratory** - CBC, liver functions tests, renal function tests, blood glucose, ESR - TSH, T4 - GH tests using insulin, clonidine - IGF - 1, cortisone - Serum Ca, phosphate, alkaline phosphatase in rickets - Karyotyping for down syndrome, turner syndrome - **Radiological** - **A. Bone age** → compared to chronological age - normal bone age exclude endocrinal causes of short stature - Delayed bone age → constitutional, malnutrition, hypothyroidism, hypopituitarism - Advanced bone age → congenital adrenal hyperplasia - **B. Wrist x - ray** → for diagnose infantile rickets ## General Examination in Patient with Cushing Syndrome (Rare) ### Face - Moon face. - Plethoric face due to polycythemia. - Acne, hirsutism, frontal balding (Virilization in female). - Violaceous color. ### Skin, Extremities - Thin, stretched, shiny (due to loss of subcutaneous tissue by collagen destruction). - Stria rubra → wide > 1 cm, depressed, purple (due to appearance of subcutaneous blood vessels. - Vascular purpura, easy bruising. - Delayed wound healing. - Hyperpigmentation → ACTH dependent only in Cushing disease not Cushing syndrome (MSH) (ACTH melanocytes hormone (pute cell)). - Extremities → Proximal muscle wasting ### Abdomen - Stria rubra. - Truncal obesity. ### Chest - Buffalo hump. - Kyphosis. - Interscapular fat deposition. ### Important OSCE Questions - To prove Cushing → cortisol level (High) - **Low dose dexamethasone suppression test** to confirm diagnosis (if not suppressed) - **To prove Cushing → cortisol level (High)** - Low dose dexamethasone suppression test → to confirm diagnosis (if not suppressed) - High dose dexamethasone suppression test → to differentiate between Cushing disease and Cushing syndrome - if cortisone hormone is suppressed → Cushing disease - if cortisone hormone is not suppressed → Cushing syndrome - **Cushing disease** → pituitary Cushing ACTH dependent - **Cushing syndrome** → Adrenal Cushing ACTH independent - **Causes of hypertension with hypokalemia** - Conn disease - Cushing syndrome - Hypertension on diuretic therapy - **Features of malignant Cushing or ectopic Cushing** - loss of weight & myopathy - Alkalosis - Hypokalemia - Hyperpigmentation (Increase ACTH)