Pearls in PACES (Endocrine- General)

Adel Hasanin
EXAMINATION OF ENDOCRINE SYSTEM
CLINICAL MARK SHEET
Examiners are required to make a judgement of the candidate's performance in each of the following
sections by filling in the appropriate box then record the overall judgement (a fail or clear fail grade must
be accompanied by clearly written explanatory comments)
1. Physical examination

2. Identification and interpretation of physical signs

3. Discussion related to the case

Overall judgement

Clear
Pass

Clear
Pass

Clear
Pass

Clear
Pass

Pass

Fail

Pass

Fail

Pass

Fail

Pass

Fail

Clear
Fail

Clear
Fail

Clear
Fail

Clear
Fail

Pearls in PACES (Endocrine- General)

Adel Hasanin
STEPS OF EXAMINATION
Step 1: Approach the patient
Read the instructions carefully for clues
Shake hands, introduce yourself
Ask permission to examine him
Step 2: General inspection: you may have been given a lead in the instructions such as look at the hands
or look at the face, however always start your visual survey systematically (Composure and complexion
hands & arms head & face eyes mouth neck, axilla & trunk legs & feet), asking yourself at
each stage, is the hands normal?, is the face normal?, etc. if it is abnormal describe the abnormality to
yourself in the mind trying to match it up with one of the common five diagnoses in endocrine station
(thyrotoxicosis, hypothyroidism, acromegaly, Cushings, Addisons)

Pearls in PACES (Endocrine- General)

Adel Hasanin
Thyrotoxicosis Hypothyroidism
(see Ch 17.
(see Ch 17.
Endocrine
Endocrine
Neck)
Neck)
Under/average
Average
built or
General
overweight,
appearance built, anxious,
(uncover
restless
apathetic,
the hair)
thinning hair,
peaches and
cream
complexion
Face (look Lid retraction Thickened and
in the
coarse facial
(staring eyes)
mouth)
features
Graves
ophthalmopathy Periorbital
(exophthalmos, puffiness, loss of
periorbital
outer third of
oedema,
eyebrows
(unreliable),
conjunctival
injection,
xanthelasma
chemosis)
Thyroid
Hands
Dry and cold
(dorsum
acropachy,
Pulse:
check for
warm and
bradycardia
tremors,
sweaty hands,
palmar
palm - feel
for warmth
erythema
and
Pulse:
sweating,
tachycardia
and finally
(note
feel the
specifically the
pulse)
presence or
absence of AF)
Fine tremors
Obvious goitre
Obvious goitre
Neck &
(nodular or
(nodular or
trunk
(including
symmetrical),
symmetrical),
the breasts,
scars
scars (hemi/total
Pubic hair,
(hemi/total
thyroidectomy)
axillae and
thyroidectomy)
the back)

Legs & feet Pretibial

myxoedema
(Graves)

Non pitting
pretibial oedema

Acromegaly

Cushings

Addisons

Coarse features

Centripetal
obesity, bruised
thin skin, with
purple striae

Medica alert bracelet,

generalized
hyperpigmentation

Prominent
supra-orbital
ridges
Large nose and
lips
Prognathism,
widely spaced
teeth and
macroglossia

Moon face,
hirsute, with
acne
Mouth
(superimposed
thrush)

Buccal mucosa
(hyperpigmentation)

Large spade
Thin skin
like, tight rings,
coarse skin and
sweaty

Goitre
Skin tags
(molluscum
fibrosum)
Acanthosis
nigricans (black
velvety
papillomas)
Hirsutism
Gynaecomastia,
galactorrhoea
Kyphosis
Large feet

Increase pad
fats above
supraclavicular
fossae (more
specific for
Cushings)
Excess
interscapular
fat (buffalo
hump)
Purple striae
Kyphosis
(osteoporosis)
Wasting (lemon
on sticks body
shape) and
oedema

Hyperpigmentation
(palmar creases)

Hyperpigmentation
(nipples and scars)
Sparse axillary and
pubic hair
Abdominal scar
(bilateral
adrenalectomy)

Hyperpigmentation

N.B. Words in Bold Italic font indicates signs of disease activity

Pearls in PACES (Endocrine- General)

Adel Hasanin
Step 3: Once you have the diagnosis look for associated features:
Thyrotoxicosis (see Ch
17. Endocrine Neck)
Lid lag: see Ch 17.
Endocrine Neck
Examine the thyroid:
see Ch 17. Endocrine
Neck
Lymphadenopathy: see
Ch 17. Endocrine
Neck
Check for tracheal
displacement: see Ch
17. Endocrine Neck
If there is a
thyroidectomy scar,
test for Chvosteks sign
(hypoparathyroidism):
see Ch 17. Endocrine
Neck
Additional findings: see
Ch 17. Endocrine
Neck
(brisk ankle jerk,
proximal myopathy,
carpal tunnel,
ophthalmoplegia, visual
field defects, fundus,
HTN & urine dipstick)

Hypothyroidism (see
Ch 17. Endocrine
Neck)
Examine the thyroid:
see Ch 17. Endocrine
Neck
Lymphadenopathy: see
Ch 17. Endocrine
Neck
Check for tracheal
displacement: see Ch
17. Endocrine Neck
If there is a
thyroidectomy scar,
test for Chvosteks sign
(hypoparathyroidism):
Ch 18. Endocrine
Neck
Additional findings: see
Ch 17. Endocrine
Neck
(slow relaxing ankle
jerk, proximal
myopathy, carpal tunnel,
ophthalmoplegia, visual
field defects, fundus,
HTN & urine dipstick)

Acromegaly

Additional
findings:

Proximal
myopathy

Carpal tunnel
syndrome

Visual field
defect
(bitemporal
hemianopia)

BP (HTN) 15%

Urine dipstick for
sugar

Abdominal
examination:
enlarged organs

Cardiac
examination:
cardiomegaly,
CCF

Joint arthropathy
(osteoarthrosis,
chondrocalcinosi
s)

N.B. Words in Bold Italic font indicates signs of disease activity

Step 4: Thank the patient and cover him (her)

Cushings

Addisons

Additional
Additional
findings:
findings:

BP

Proximal
myopathy
(supine
(stand from
and
sitting or test
standing)

Chest
shoulder
(TB)
abduction)

Urine

Visual field
dipstick
defect:
bitemporal
hemianopia
and
pigmentation
(pituitary
tumour)

Fundus: optic
atrophy,
papilloedema,
hypertensive
or diabetic
retinopathy

Signs of RA or
asthma
requiring
steroids
(iatrogenic
Cushings)

BP and urine
dipstick