Endocrine System

 

 

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I. Structured History Taking Points

1. Chief Complaints

• Weight Changes:

  • Weight gain:
    • Rapid: Cushing’s syndrome, hypothyroidism.
    • Gradual: Hypogonadism, insulinoma.
  • Weight loss:
    • With increased appetite: Hyperthyroidism, diabetes mellitus.
    • Without increased appetite: Addison’s disease, pituitary insufficiency, malignancy.

• Temperature Intolerance:

  • Heat intolerance: Hyperthyroidism.
  • Cold intolerance: Hypothyroidism.

• Change in Skin, Hair, Nails:

  • Dry, coarse skin, brittle nails, hair fall: Hypothyroidism.
  • Fine hair, hyperhidrosis: Hyperthyroidism.
  • Skin hyperpigmentation: Addison’s disease.
  • Striae, thin skin: Cushing’s syndrome.

• Menstrual/ Sexual Dysfunction:

  • Menorrhagia, amenorrhea: Hypothyroidism, PCOS.
  • Oligomenorrhea: Hyperprolactinemia.
  • Erectile dysfunction: Hypogonadism, DM.

• Polyuria, Polydipsia:

  • Diabetes mellitus, Diabetes insipidus, Hypercalcemia.

• Neck Swelling:

  • Goitre, thyroid nodules, thyroglossal cyst.

• Growth Disorders:

  • Short stature: GH deficiency, hypothyroidism.
  • Tall stature: Marfan’s, acromegaly.

• Lethargy, Fatigue, Myopathy:

  • Hypothyroidism, Cushing’s, Addison’s.

• Symptoms of Raised ICP, Vision Changes:

  • Pituitary macroadenoma.

• Fractures, Bone Pain:

  • Osteoporosis, hyperparathyroidism.

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2. Associated Symptoms

• Palpitations, tremors → Hyperthyroidism.
• Constipation → Hypothyroidism.
• Diarrhea → Hyperthyroidism.
• Polyphagia → DM, hyperthyroidism.
• Hyperpigmentation → Addison’s.
• Headache, galactorrhea → Prolactinoma.
• Mood changes → Thyroid disorders, Cushing’s.

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3. Past History

• Diabetes, hypertension, autoimmune disease.
• Previous neck surgeries, irradiation.
• Family history of thyroid, pituitary, adrenal disorders.

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4. Drug History

• Steroid use, antithyroid drugs, lithium, amiodarone.

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5. Lifestyle History

• Diet, physical activity, stress factors.

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II. Advanced Clinical Examination

A. General Examination

• Build & Nutrition:

  • Obesity → Cushing’s, hypothyroidism.
  • Cachexia → Addison’s, pituitary insufficiency.

• Facies:

  • Moon face → Cushing’s.
  • Myxedematous facies → Hypothyroidism.
  • Acromegalic facies → Acromegaly.
  • Exophthalmos → Graves’ disease.
  • Pigmented lips → Addison’s.

• Skin & Hair:

  • Hyperpigmentation → Addison’s.
  • Striae → Cushing’s (purple, broad).
  • Vitiligo → Autoimmune thyroiditis.
  • Dry, coarse skin → Hypothyroidism.
  • Hyperhidrosis → Hyperthyroidism.
  • Hirsutism → PCOS, Cushing’s.
  • Alopecia → Hypothyroidism, hyperandrogenism.

• Nails:

  • Onycholysis (Plummer’s nails) → Hyperthyroidism.
  • Brittle nails → Hypothyroidism.

• Hands:

  • Tremors → Hyperthyroidism.
  • Palmar erythema → Hyperthyroidism.
  • Carpal tunnel signs → Hypothyroidism.
  • Doughy hands → Myxedema.
  • Acromegalic features → GH excess.

• Vitals:

  • Bradycardia → Hypothyroidism.
  • Tachycardia → Hyperthyroidism.
  • BP: Hypertension (Cushing’s), Postural hypotension (Addison’s).
  • Temperature: Low in hypothyroidism, high in thyrotoxic crisis.

• Gait:

  • Proximal myopathy gait → Cushing’s, hypothyroidism.

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B. Systemic Examination

1. Neck Examination (Thyroid):

• Inspection & Palpation:

  • Goitre: Diffuse (Graves’, Hashimoto), Nodular (MNG, carcinoma).
  • Surface: Smooth (physiological), nodular.
  • Consistency: Soft (Graves’), firm (Hashimoto’s), hard (Malignancy).
  • Tenderness: Subacute thyroiditis.
  • Mobility: Moves with deglutition (thyroid), with tongue (thyroglossal cyst).
  • Bruit: Graves’ disease.
  • Pemberton’s sign: Retrosternal goitre.

• Percussion:

  • Retrosternal dullness → Substernal goitre.

• Auscultation:

  • Thyroid bruit → Graves’.

2. Eye Signs:

• Lid retraction, lid lag → Hyperthyroidism.
• Exophthalmos, chemosis → Graves’.
• Periorbital edema → Hypothyroidism.

3. Chest & Cardiovascular:

• Arrhythmia → Hyperthyroidism.
• Hypertension → Cushing’s.
• Pericardial effusion → Hypothyroidism.

4. Abdominal Examination:

• Central obesity, purple striae → Cushing’s.
• Hepatomegaly → NAFLD in metabolic syndrome.
• Palpable adrenal mass → Pheochromocytoma.

5. Neuromuscular:

• Reflexes:
  • Delayed relaxation → Hypothyroidism.
  • Brisk → Hyperthyroidism.
• Muscle wasting → Cushing’s, thyrotoxicosis.

6. Genitalia & Secondary Sexual Characters:

• Sparse axillary/pubic hair → Addison’s, hypogonadism.
• Gynecomastia → Klinefelter, Cushing’s.
• Clitoromegaly → Congenital adrenal hyperplasia.

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III. Advanced Clinical Clues & Differential Interpretations

• Hyperpigmentation + Postural hypotension + Weight loss:

  • Addison’s disease.

• Moon face + Buffalo hump + Central obesity + Striae:

  • Cushing’s syndrome (endogenous or exogenous).

• Heat intolerance, tremors, tachycardia, weight loss:

  • Hyperthyroidism (Graves’, toxic MNG).

• Fatigue, cold intolerance, constipation, bradycardia, weight gain:

  • Hypothyroidism (Primary, secondary).

• Acromegalic facies + Enlarged hands/feet + Proximal weakness:

  • GH excess (Pituitary adenoma).

• Bitemporal hemianopia + Galactorrhea + Amenorrhea:

  • Pituitary macroadenoma (Prolactinoma).

• Polyuria, polydipsia, high serum sodium:

  • Diabetes insipidus (Central or Nephrogenic).

• Short stature + Delayed puberty + Hyponatremia:

  • Panhypopituitarism.

• Neck swelling with compressive symptoms, hoarseness:

  • Large goitre, carcinoma thyroid.

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