Examination of the endocrine system includes questioning the patient about symptoms, examining the neck area, palpating the thyroid gland, and measuring the neck circumference. Questioning focuses on complaints related to the thyroid, pituitary, adrenal and other endocrine glands. Examination of the neck looks for enlargement of the thyroid and specific facial features of hyperthyroidism. Palpation assesses the size, consistency and mobility of the thyroid gland. Diseases of the endocrine system can cause hormonal imbalances and symptoms affecting multiple organ systems. Acute endocrine emergencies like hyperthyroid crisis and myxoedema coma require prompt treatment to prevent mortality.

1. Examination of the
endocrine system
Koshukeeva Anara

2.  Examination of the endocrine system includes questioning,
examination of the neck area and palpation of the thyroid
gland (if necessary, also percussion and auscultation),
measurement of the neck circumference at the level of
the thyroid gland, determination of specific eye
symptoms.

3. Questioning the patient.
 Complaints of patients with endocrine diseases can be
very diverse, affecting the functions of other organs and
systems.
 Patients present complaints about:
- increased excitability, sleep and memory disturbances,
- irritability and sweating (hyper- and hypothyroidism);
- fever, increased sweating, feeling of heat, poor
tolerance of high ambient temperatures (hyperthyroidism)
- pain in the region of the heart, palpitations and a feeling
of interruptions in the work of the heart (hyperthyroidism,
pheochromocytoma);

4. Questioning the patient.
• impaired appetite, dyspeptic symptoms, thirst (chronic
adrenal insufficiency, hyper- and hypothyroidism, diabetes
mellitus);
• itching (especially in the genital area), a tendency to fungal
skin lesions, furunculosis (diabetes mellitus);
• weight loss (diabetes mellitus, adrenal insufficiency,
hyperthyroidism), overweight (diabetes mellitus, alimentary
obesity, hypothyroidism);
• sexual dysfunction (hypogonadism, Itsenko-Cushing's
syndrome)

5.  An important role in the history of diseases of the endocrine
system is played by such factors as mental trauma, the
presence of chronic infection and heredity.
 Family history is important. The risk of developing diabetes
increases in women who have given birth to a live or dead
child weighing more than 4.5 kg
 Find out the nutritional characteristics of patients.
For example, easily digestible carbohydrates can lead to
obesity and the development of type II diabetes mellitus

6.  A special place is occupied by iatrogenic causes - long-term treatment
with preparations of iodine, lithium, cordarone (hypothyroidism),
glucocorticoids (hypercortisolism).

7. Thyroid examination
 When examining the anterior surface of the neck, a pronounced
enlargement of the thyroid gland (goiter) can be detected, sometimes
leading to a sharp change in the configuration of the neck.
 When examining the face, it is possible to identify a specific facial
expression - facies basedovica (with hyperthyroidism), characterized by:
 abnormal widening of the eye slits with normal gaze;
- shine in the eyes
- bulging eyes (exophthalmos);
- retraction of the upper eyelid with a quick change of sight Kocher's
symptom;

8. Facies basedovica

9.  Examination of the neck area reveals an enlargement of
the thyroid gland when it is affected (diffuse goiter,
malignant tumor).
 The main clinical method for the study of the thyroid
gland is her palpation.

10.  There are three most common
ways to palpate the thyroid gland.
In the first method of palpation, the
doctor, located in front of the patient,
deeply puts the bent II-V fingers of both
hands behind the posterior edges of the
sternocleidomastoid muscles, and places
the thumbs in the area of the thyroid
cartilage inwardly from the anterior
edges of the sternocleidomastoid
muscles.
During palpation, the patient is asked to
make a swallowing movement, as a
result of which the thyroid gland moves
upward with the larynx and moves under
the doctor's fingers.

11. In the second method of palpation, the doctor is located to
the right and slightly in front of the patient.
 Palpation of the thyroid
gland is carried out fingers
of the right hand, and
palpation of the right lobe
is carried out with the
thumb or index finger, and
palpation of the left lobe -
with the rest of the fingers
folded together.

12. With the third method of palpation, the doctor
stands behind the patient. The thumbs are located
on the back of the neck

13.  On palpation, the consistency, nature of the increase,
pain and mobility of the thyroid gland are assessed.
there are 5 degrees of its increase:
• 1 d - the gland is not visible, but the isthmus is palpable;
• 2 d - the lateral lobes, the gland are well felt when
swallowing;
• 3 d - the gland is visible on examination ("thick neck");
• 4 d - a significant increase in the thyroid gland
• 5 d - a goiter of huge size.

14. After palpation, the neck circumference is measured at the
level of the thyroid gland.
Percussion can be used to detect a retrosternal goiter.
During auscultation of the thyroid gland,in patients with diffuse
toxic goiter, in some cases it is possible to hear functional noise

15. Hypothalamic–Pituitary Axis
 The hypothalamus affects several
nonendocrine functions,. including
appetite, sleep, body temperature, and
activity of the autonomic nervous system.
 In addition, the hypothalamus modulates the
pituitary hormone secretions
 The pituitary gland is located in the anterior
fossa, in the sella turcica, in close proximity
to the optic chiasm

16. Pituitary Hormones

17. Questioning the patient.
• pain in bones and joints (acromegaly, hyperthyroidism),
• bone fractures (Itsenko-Cushing's syndrome, hyperparathyroidism);
• changes in the shape and size of the bones of the limbs, lower jaw,
zygomatic bones, (acromegaly);
• the appearance of convulsive muscle contractions: the patient's hand
takes the form of an "obstetrician's hand", and the face changes with the
creation of the so-called "fish mouth" (hypoparathyroidism);
• dry skin, fragility and hair loss, itchy skin tendency to manifestations of
local infections (hyper- and hypothyroidism, diabetes mellitus);
• headaches, "noise" in the head associated with arterial hypertension
(pheochromocytoma, hypercortisolism);
• muscle weakness (Addison's disease, Cohn's and Itsenko-Cushing's
syndromes);

18. Diseases of the hypothalamus – pituitary
system
Pituitary disease may manifest with pituitary hormone excess or
deficiency or symptoms of mass expansion, including headaches and
visual disturbances.
Pituitary adenoma is the most common cause of pituitary dysfunction
in adults
Evaluation of pituitary function (deficiency or excess) involves imaging
and serum measurements of prolactin, insulin-like growth factor type
1 (IGF-1), free thyroxine (FT4), TSH, adrenocorticotropic hormone
(ACTH), cortisol, luteinizing hormone (LH), follicle stimulating
hormone (FSH), testosterone (in men), and estradiol (in women).

19. Diseases of the hypothalamus – pituitary
system
are rare, annual incidence of approx 1: 50 000 subjects.
Disorders of the hypothalamus and pituitary may present as
endocrine or neurologic dysfunction.
 I. Hypersecretion (prolactinoma, acromegaly, central
Cushing´s disease) /hyposecretion (hypopituitarism,
adrenal insufficiency, central hypogonadism) of pituitary
hormones,
 II. neurological manifestations (space occupying lesions,
headache, visual disturbances) - due to pressure effects
from tumor or cause abnormal autonomic function.

20. HYPOPITUITARISM
-Hypopituitarism refers to total or partial deficiency of one
or more pituitary hormones.
-Hypopituitarism could be the result of a genetic cause; a
deficiency in hypothalamic releasing factor; or, more
commonly, the result of pituitary tissue destruction
secondary to mass expansion, infiltrative process
-Approximately 10% of patients with empty sella syndrome
have clinically apparent hypopituitarism, and some may
have pituitary adenomas.

21. HYPOPITUITARISM
Clinical Manifestations
The clinical manifestations of hypopituitarism are highly
variable and depend on the age and sex of the patient as well
as on the etiology of the pituitary disease
Patients can be completely asymptomatic for many years or
present with dramatic symptoms of nausea, vomiting,
headache, and vascular collapse.

22. HYPOPITUITARISM
Diagnosis
If one pituitary hormone insufficiency is documented, the other
pituitary hormones should be tested.
An 8 AM plasma cortisol level below 3 µg/dL strongly suggests
hypocortisolism. A level 18 µg/dL or greater excludes ACTH
deficiency
Treatment
Hydrocortisone is given to adults at 20 to 30 mg/day and
increased during times of illness and other stresses.
Serum concentration and growth rate in children are used for
monitoring the effectiveness of GH replacement

23. Thyroid disease
 Thyroid disease is common in its various types, affecting some
5% of the population, predominantly females. The thyroid
secretes thyroxine (T4) triiodothyronine (T3)
Hypothyroidism – disease of the thyroid gland – low T4 T3 levels
– combined by high circulating TSH levels.
Hyperthyroidism – disease of the thyroid – – high T4 T3 levels –
TSH secretion is suppressed
Subclinical hyperthyroidism: Normal T4,T3, suppressed TSH
Subclinical hypothyroidism: Normal T4, T3, raised TSH

24. Hyperthyroidism
 Clinical features of hyperthyroidism Goitre
Gastrointestinal
*Weight loss (despite normal or increased appetite)
*Diarrhoea and steatorrhoea *(Anorexia and Vomiting)
Hepatic dysfunction *Hyperbilirubinemia, (slightly raised)
*AST, ALT, GMT, ALP (slightly raised) (from bone and liver)
Cardiorespiratory *Palpitations, sinus tachycardia atrial
fibrillation *Increased pulse pressure *Ankle oedema in
absence of cardiac failure *Angina pectoris, cardiomyopathy
and cardiac failure *Dyspnoea on exertion *Exacerbation of
asthma

26.  Management of hyperthyroidism of Graves´disease
A) Antithyroid drugs First episode in
patients < 40 yrs Thionamids Carbimazol: (1-metyl-2-thio-3-
karbetoxyimidazol) Carbimazol Slovakofarma 5 mg tbl.,
Carbimazol Henning 5 mg tbl., Carbistad Stada Arzneimittel
5 mg tbl.,
Methimazole: (active metabolite of carbimazole) (1-metyl-
2-merkaptoimidazol)
Thiamazol Henning, 5, 20 mg tbl., amp 40 mg
Tapazol Lilly, Favistan Biochemie, Kundl 20 mg tbl or 1 m
inj. form 40 mg

27. Hypothyroidism
 Increased TSH – 1st symptom of starting hypothyroidism: subclinical hypothyroidism
characterized by normal level of peripheral thyroid hormones (T4,T3) increased
level of TSH.
Clinical features of hypothyroidism depend on the form, duration and severity of
hypothyroidism
General
• Tiredness, somnolence * Weight gain * Cold intolerance * Hoarseness (voice) *
Goitre Cardiorespiratory * Bradycardia, angina pectoris, cardiac failure *
Xanthelasma * Pericardial and pleural effusion
• Neuromuscular * Muscle stiffness (aches and pains) * Delayed relaxation of tendon
reflexes * Depression, psychosis * Cerebellar ataxia * Myotonia * Carpal tunnel
syndrome * Deafness, Cretinism

28.  Management
Supplementation with T4 50…100…150 μg daily Monitoring
therapy! Correct dose of T4 restores serum TSH to the lower
part of the reference range (0,35 – 4,2) i.e. 2,0 – 2,5 mU/l

29. Simple goitre
 Diffuse, or multinodular enlargement of thyroid, occurs
sporadically, unknown ethiology. Suboptimal iodine intake,
minor degree of dyshormonogenesis, epidermal growth
factor, immunoglobulins may play a role. Patient female,
euthyroid familial history of goiter
 Simple diffuse goitre Goitre is soft and symmetrical,
thyroid is enlarged to 2 or 3 times, tight sensation in the
neck when swallowing T4, T3, TSH normal, no thyroid
antibodies. No treatment is necessary, sometimes the
thyroid enlarge persists → simple multinodular goitre

30. Thyroiditis
 Acute thyroiditis (Bacterial thyreoiditis) A bacterial induced inflammation of
the thyroid (Staphylococcus, streptococcus, pneumococcus, E.colli, mycotic
infection Patient female : male ratio 3:1
 Clinical features Spontaneous pain in the region of the thyroid with radiation
to the jaw, ears, painful by swallowing, coughing, movement of the neck,
swelling of the gland, mildly enlarged painful at the palpation
 Management Broad spectrum antibiotics (TTC), abscess - surgical intervention
drainage of thyroid

31. Acute situations in endocrinology
 Acute situations – emergency, alarm - situations in endocrinological
practice are not common but life-threatening complications which
require an urgent and complex therapeutical aproach to the patients.
Dispite of intensive care and early recognition / diagnosis the
mortality rate is relatively high 10 - 50%. The aim of medical care is to
exert a sufficient prevention, perfect diagnostics and an effective
therapy for saving the life of patient

32. Hyperthyroid crisis
 A rare but life-threatening increase in the severity of the clinical
features of hyperthyroidism. Clinical features and signs: agitation,
confusion, fever, tachycardia or atrial tachyfibrillation, older patient -
cardiac failure Medical emergency – mortality rate was 50%, recenly
10 %, despite early recognition and treatment. Intensive care unit!
 Management of crisis
Rehydratation, broad spectrum antibiotic beta-blockers (propranolol) 80
mg 6-hourly orally (p.o. application) or 1-5 mg 6-hourly intravenously
(i.v. (parenteral application) antithyroid drugs: Carbimazol 40-60 mg
daily orally (inhibition of hormone systhesis)

33. Myxoedema coma
 A rare presentation of developed severe hypothyroidism
Depressed level of consciousness elderly patients with
myxedematous types Body temperature as low as 25°
Celsius. Mortality rate is 50% survival chance depends
upon early recognition and treatment of hypothyroidism.
Treatment must begin before biochemical confirmation of
the diagnosis. Hydrocortisone sodium succinate 100 mg