Saturday, 17 October 2015

Clinical Examination of Endocrine system

Clinical Examination of Endocrine system

By Prof.Dr.R.R.Deshpande ( MD in Kayachikitsa & MD in Sharirkriya)

From his own book of Clinical Examination with Dr.Subhash Ranade .Narendra Prakashan .Rs.120/-


(1) Examine Body Size & Proportions of different organs.
Note - Height, weight, fat Distribution, Limb & trunk Dimensions.

(a) Look for Gigantism, Acromegaly (Hyperpituitarism),
Dwarfism in children (Hypo pituitarism ), Obesity of trunk with relatively thin limbs (cushing’s syndrome due to cortical Hyperadernalism). Tall thin stature, long limbs & youthful appearance in Klinefelter’s syndrome (by failure of testicular development at puberty); Enlargement of peripheral parts ( Large nose, large & prominent lower jaw & big hands) - seen in Acromegaly.

(b)Loss of weight is seen in Diabetes mellitus & Hyperthyroidism.

(2) Examine Hair - for Amount, Texture & Distribution.

(a) Excessive Adrenal cortical function or ovarian tumours in
women- show musculine distribution of hair over the faces, limbs & trunk. (Hirsutism)

(b) In Ant Hypopituitarism & in Addison’s Disease (in wommen)
Loss of pubic & axillany hair. (simmands sheehan Disease)

(c) Eyebrows & Hair on scalp become sparse & Dry in -Hypothyroidism.

(3) Examine Skin - For Temperature, texture, moisture, pallor,
Pigmentation, Bruising, Acne, striae.

(a) Thinning & striation of skin, purpura, due to Increased
capillary fragility seen in -Long term cortico steroid therapy (Cushing’s syndrome)

(b) Dark drown colouring on face, hands, in cutaneous areas &
parts of budy - exposed to light or pressure. Occurs also, where
pigmentation normally more eg axillae, areolae of nipples, around
genitalia -seen in diminished function of Adrenal cortex (Addison’s
disease) - patchy darkening of oral mucaus membrane is confirmatory sign.

c) Skin cold & dry -in Hypothyroidism.

(3) Examine Facies – Like

(a) Acromegalic- Prognathism, enlarged nose & ears, prominent
supercilliary arches.

(b) Myxoedematous facies- puffy eyes, full nose & Lips, pallid
complexion.
(c) Cushingoid facies- High colour, mooning of face (& also acne
on chest)

(4) Examine- Eyes – for Acuity & field of vision, Exophthalmos, ocular pareses, cataract,Retionpathy, Optic Atrophy.

(a) Compression of structures, adjacent to pituitary tumour can
give Eye problem (so, examine for field of vision, optic fundi &
Oculomotor nerves )

(b) Exophthalmos – abnormal prominence of eyes. In severe cases, may be associated with chemosis, corneal lceration,visual impairment, oculomotor paresis (Exopthalmic opthalmoplegia)
Exopthalmos is caused by infiltration of orbital tissues, with a cellular & muco-protein  exudate.Exopthalmos is seen in Hyperthyroidism.Von Graefe’s sign- To demonstrate lid-lag
the Doctor moves his finger slowly down from above. The seated
patient is asked to watch the finger all the way, upper eyelids is then seen to lag behind the eyeball.

(C) Deposits of Non - pitting myxoedemas ® can be seen in
lower eyelids (& supra clavicular fossae.)

(5) Examine mouth – for

(a) Dehydration (Dry tongue) - In polyuria (Diabetes Insipidus
 due to deficiency of ADH); Sodium depletion (In ACTH
insufficiency- seen in addison’s disease or Hypopituitarism )

(b) Patchy darkening of oral mucous membrane in Addison’s
disease.

(6) Examine Neck – For

(a) Thyrold tumour
- Goitre moves upwards during swallowing.
- palpation (Doctor stands behind the patient) - Diffuse & soft
in primary Grave’s disease. One or more firm localized nodules in Toxic  nodular Goitre. Over active or vascular goitre give - soft, blowing  systolic murmur over goitre. (Murmur is not present in Non toxic Goitre)

(b) Parathyroid tumour - Parathyroid Adenoma gives condition
of Hyperparathyroidism ( Generalized Ostitis fibrosa cystica)

(7) Examine cardiovascular system for - Hypertension,
Hypotension,  Heart Rate & Rhythm.

(a) Hyperthyroidism - Palpitations,Tachycardia (Persists during sleep,) Complication- Cardiac failure.

(b) Hypothyroidism – Bradycardia .complication - Atheromatous coronary artery disease, due to disturbed lipid metabolism.

(c) Hypopituitarism - Hypotension.

(d) Cushing’s syndrome - (Adrenal cortical hyperplasia) - prolonged use of  corticosteroid .Hyperthyroidism -
Disability & prognosis, depends on cardiovasclar effects of
accompanying D.M, Hypertension.

(e) Conn’s syndrome (Rare) - due to Aldosterone secreting
tumour. - Hypertension due to sodium Retention.

(f) Addison's Disease - (Hypoadrenalism - diminished function
of Adrenal cortex )- Due to Low Na+ & Cl– -dehydration ®
Hypotension.

(g) Hyper-adrenalism - medullary (Phaeochromocytoma) -
Attacks of sweating & trembling with dramatic rise of B.P

(h) D.M- Diabetic keto acidosis - Vomiting, Dehydration,
Hypotension.

(8) Examine - Respiratory system for - Hyperventilation or
Hypoventilation.

(a) Hyperthyroidism - Dyspnoea

(b) Diabetic keto acidosis - Hyperventilation due to acidosis
(Air Hunger.)

(9) Examine - Abdomen for Adrenal or panereatic tumour & for G I tract problems.

(a) Hyperthyroidism - Diarrhoea

(b) Hypothyroidism - constipation (complication -Intestinal
obstruction from paralytic ileus)

(c) Hypoadrenalism - Cortical - Addisonian crisis- Dehydration
+ Hypotension + abdominal tenderness.

(d) Hyperparathyroidism - Excessive mobilization of Ca from
bones. So hypercalcaemia can cause peptic ulceration.

(10) Examine - Genitalia - For size & configuration of genitalia &
breasts.

(a) Adults Hypopituitarism - Impaired sexual function, Genital
Atrophy.

(b) Hyperadrenalism - cortical (Adrenal virilizing syndrome)-
Clitoris is enlarged (Mistaken for a penis & fused labia for a scrotum - so infant may be brought up as a boy - which is pseudo - hermaphroditism. ) In boys - Precocious development of secondary sex character.

(C) Primary Testicular Defects - Eunuchoidism - Abscence
or Infantile character of testes. (Mumps with orchitis may also be
causative factor)

(d) Klinefelter’s syndrome - Failure of Testicular development
at puberty & enlargement of mammary glands.

(e) Turner’s syndrome - In women, deficiency in ovarian
function results into Amenorrhoea & lack of feminine contour.

(11) Examine - Nervous system for mental changes, stupor, Tremors, Tetany, Refiexes.

(a) Hyperthyroidism - Nervousness, Tremors of out stretched
hands, sweats, Intolerance to Hot weather.Complication - Psychosis.

(b)Hypothyroidism - Lethargy, Difficulty in concentration, feeling
of cold, slowing up of patient's physical & mental processes, Deafness, movements are sluggish, reactions delayed, voice-slow, deep & husky, Delayed relaxation of Tendon reflex responses. Thyroid deficiency in children - cretinism - mental Retardation. Complication - Organic psychosis (myxoedema madness)

(c) Hyperadrenalism - medullary - phaeochrmocytoma- Attacks
of sweating, trembling, fear & pallor.

(d) Hyperparathyroidism - Hypercalcaemia causes mental
disorders.

(e) Hypoparathyroidism - Hypocalcaemia causes mental
derangement & convulsions.

(f) Diabetic Keto acidosis - Drowsiness & coma .Complications of D.M - strokes & ischaemic changes, in toes (Gangrene), Diabetic Neuropathy ® paraesthesiae with Loss of ankle
jerks & vibration sense.

(g) Hypoglycemia - Faintness, dizziness, sweating. (Hunger,
palpitation - all relived by taking sugar)
(12) Examine muscuto skeletal system for kyphosis, fractures & deformities.

(a) Hyperpituitarism - Gigantism in childhood & Acromegaly
in adults. Aeromegaly - Supercilliary arches, cheek bones, Lower jaw are greatly enlarged. (Prognathism = Projecting jaw) Teeth are separated by enlargement of jaw, Hands & feet are enlarged, kyphosis

(b) Hypopituitarism - Dwarfism.

(c) Cushing’s syndrome - (obesity of trunk ) with relatively thin
limbs, kyphosis.

(d) Klinefelter’s syndrome - (failure of testicular development
at puberty) - Tall, thin stature, long limbs & youth full appearance.

(e) Hyperparathyroidisn - Excess mobilization of Ca from
skeleton leads to tender swellings & deformity of bones (Generalized osteitis fibrosa cystica.)

(f) Hypoparathyroidism - Most IMP sign is “Tetany”- Diagnosis by carpopedal spasms (Hands are in a state of painful
spasm with fingers tightly apposed, thumb flexed & adducted across palm, terminal phalanges hyper extended, wrist flexed.

- Trousseau’s sign - Squeezing the arm (arm can be
compressed by cuff of sphygmomanometer.) or leg & evoking
carpopedal spasms, which are latent.

- Chvostek’s sign - Tapping over facial Nerve, as it emerges
from stylomastoid foramen; which will cause catraction of facial muscles on one side & angle of mouth is drawn up

Prof.Dr.R.R.Deshpande
9226810630



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