Clinical Endocrinology Round

Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
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Acromegaly
Dr. Usama Ragab Youssif

Personal History
 N
 A = gigantism versus acromegaly
 S = male (macroadenoma) versus female (microadenoma)
 O
 M = married or divorced
 R
 H
 H

Chief complaint
 Pain
 Swelling
 Disturbance of function
+ duration

Endocrine Symptomatology
 Alteration in height, e.g. increase or decrease
 Weight gain or loss
 Polyuria and polydipsia
 Menstrual irregularity
 Thyroid swelling with or without signs of thyrotoxicosis
 Hypothyroidism or its features
 Gynaecomastia
 Hirsutism
 Myopathy or muscle weakness.

Example of Chief complaint in acromegaly
 Progressive enlargement of the body for … months
 Weakness and weight gain for … months
 Change in voice for … months
 Headache for … months
 Joint pain for … months
 Excessive sweating for … months.

Present history
 Analysis of complain: Chronological order of symptoms, mode of
onset, their progression and course
 Analysis of symptoms of the same system
 Ask for associated symptoms
 Investigations done (related to symptoms)
 Treatment taken: e.g. replacement therapy or oral contraceptives.

Present history
 General = sweating + heat or cold intolerance + appetite
 CVS = symptoms of HF, HTN….
 Chest =
 NS = central or peripheral +/- psychiatric
 GIT = polypi

Example of Present history in acromegaly
 According to the statement of the patient, he was reasonably well
… years back. Since then, he has been experiencing progressive
enlargement of body, mainly his head, hands and feet. His face is
also enlarged, including the jaw, leading to difficulty in chewing. He
also complains of severe weakness despite significant weight gain.
His voice has recently changed and become hoarse.
 The patient also complains of frequent headache involving the
whole head, more marked in the morning, which is not associated
with nausea or vomiting.

Present history (cont.)
 For the last … months, he is also complaining of joint pain involving
both the knees, ankles and elbows. The pain is aggravated by
activity and relieved by taking rest. It is not associated with morning
stiffness. Recently he noticed excessive sweating even at rest.
There is no history of any visual disturbance, cold intolerance,
sleepiness. His bowel and bladder habits are normal.

Past History
 Drugs
 Operation: previous surgery or radiation
 Disease

Family history
 DM or any other endocrinal or autoimmune disease.
 Similar condition in the family = familial acromegaly

Sexual History
 Erectile dysfunction
 Loss of libido
 Dry ejaculation
 Galactorrhea
 Amenorrhea
 Irregular menses
 Dysfunctional uterine bleeding
 Details of pregnancies or PPH
in females
Menstrual & Obestetric
History

General examination
Vital signs General overview
 Pulse
 BP
 Temperature
 Respiratory rate
 Appearance
 Built
 Color
 Decubitus
 Exposure: back & genitalia
 Facial expression
 Gait
 Mental

General examination
Regional examination Systemic examination
 Head & Neck
 Upper limbs
 Lower limbs
 CVS
 Chest
 Abdomen
 CNS

General Examination
 Appearance, built, height, weight BMI and body proportions
 Face, e.g. periorbital oedema, moon-facies, prognathism, etc.
 Eyes, e.g. exophthalmos, proptosis, signs of Grave’s ophthalmopathy,
visual acuity
 Ear, e.g. deafness, size
 Mouth, e.g. large protruding tongue, thick lips, etc.
 Neck, e.g. goitre, carotid, pulsations/bruit, JVP.

Face
 Look at the face for
coarsening of features, thick,
greasy skin, prominent
supraorbital ridges,
enlargement of the nose,
prognathism (protrusion of the
mandible) and separation of
the lower teeth.
 Ask patient to open his mouth
and show his teeth

Upper & lower limbs
 Shake hands!!
 Examine the hands and feet
for soft-tissue enlargement
and tight-fitting rings or shoes,
carpal tunnel syndrome and
arthropathy
 Large feet

Visual field
 Bitemporal hemianopia

Genitalia & breasts
 Look genitalia for hyper or hypogonadism
 Virilisation
 Breast development, atrophy and galactorrhoea.

Systemic examination
CNS CVS
 Look for higher function,
cranial nerve, speech
 Look for abnormal movements
 Motor system examination for
brisk or delayed jerks or
myopathy
 Sensory system examination
for neuropathy including
carpal tunnel syndrome
 Look for cardiomegaly
 Auscultate for change in heart
rate, rhythm, murmur or any
other abnormal sound

Muscloskeletal GIT
 Look for osteoporosis, crush
fractures or arthropathy
 Tongue
 Organomegaly
 Stria

Example of General examination in
acromegaly
 The patient looks obese with large coarse face, large jaw with
widely apart teeth prominent supraorbital ridge, increased wrinkling
of the forehead and baggy eyelids. Nose, lips and ears are large
 Scalp is large (bulldog scalp)
 Hands are large, warm and sweaty with doughy feeling, fingers are
spade like
 Feet are large

General examination (cont.)
 Skin is thick, greasy, and sweaty (hyperhydrosis)
 Coarse body hair
 Voice is husky, cavernous
 Gynecomastia: Present
 Clubbing: Present (involving all fingers and toes)

General examination (cont.)
 Thyromegaly (diffusely enlarged)
 There is no anemia, jaundice, cyanosis, koilonychia, leukonychia,
edema
 There may be kyphosis, scoliosis, axillary skin tag, acanthosis
nigricans.

Example of Systemic examination in acromegaly
GIT Nervous system
 Tongue, lips and jaw are
enlarged. Lower jaw is
protruded with malocclusion of
teeth (prognathism).
 Abdomen—hepatomegaly
(may be).
 Voice is hoarse, husky and
cavernous.
 Visual field defect—bitemporal
hemianopia.

Systemic examination (cont.)
CVS Skeletal
 Cardiomegaly (evidenced by
shifting of the apex beat,
which is heaving).
 Both the knee and ankle
joints, elbow joints, also joints
of hands are tender, but no
restricted movement.

My diagnosis is
Acromegaly
Associated (complicated) with
diabete or HTN or whatever…

What are the changes in the eyes in
acromegaly?
 Visual field defect, usually bitemporal hemianopia (due to pressure
on optic chiasma).
 Others—optic atrophy, papilledema, angioid streaks in retina.

What are the causes of prominent supraorbital
ridge?
 Rickets
 Paget's disease
 Achrondroplasia
 Hydrocephalus
 Hereditary hemolytic anemia.

What are the causes of macroglossia?
 Acromegaly
 Hypothyroidism
 Amyloidosis
 Down's syndrome.

You are in the examination theatre

Many a times, examiner used to ask:
 ‘Look at the face. What is your diagnosis? What else do you want
to examine?’
 ‘Examine the neck of this patient.’
 ‘Perform the general examination’.
 ‘Examine the hands of this patient’.

Underlying diagnoses by looking at the face may
be:
 Graves’ disease (hyperthyroid, euthyroid or hypothyroid) or
thyrotoxicosis (due to any cause).
 Hypothyroidism (myxoedema).
 Cushing’s syndrome.
 Acromegaly.
 Pigmentation (in Addison’s disease).

Subsequent physical examination depends on
your diagnosis
 If your diagnosis is thyroid disease: further clinical examination will
be related to thyroid problems, e.g., signs of thyrotoxicosis, signs of
hypothyroidism, examination of the eye, thyroid gland etc.
 If your diagnosis is Cushing’s syndrome: examine other findings in
relation to this (central obesity, striae, proximal myopathy, blood
pressure).
 If acromegaly is suspected: then examine the face, hand, visual
field, voice.

Addison

Personal history
 N
 A
 S
 O
 M
 R
 H

Chief complaint
 Weakness and weight loss for … months.
 Loss of appetite, nausea, dizziness and vertigo for … months.
 Pigmentation in different parts of the body for … months.

Chief complaint (cont.)
 Orthostasis, syncopal attack + salt craving
 Chronic diarrhea + weight loss
 Non specific symptoms + lack of sensation of well being
 Toxic manifestation of TB?

Present history
 According to the statement of the patient, she was reasonably well
…months back. Since then, she has been suffering from severe
weakness with gradual loss of about 10 kg of bodyweight. The
patient also complains of loss of appetite, nausea, dizziness and
vertigo for the last … months.
 Her dizziness and vertigo are more marked when sitting from lying
position and on standing.

Present history (cont.)
 There is no history of fever, cough, bowel or bladder abnormality,
excessive sweating, palpitation or heat intolerance.
 For the last … months, she also noticed some pigmentation
involving different parts of the body. There is no history of injury or
recent scar.

Past history
 Nothing significant
 We need to exclude drug history: steroids
 She gives no history of tuberculosis, abdominal trauma or surgery.
 Ask for blood donation?

Menstrual history
 Amenorrhea for the last 4 months, but it was regular previously.

Family history
 Irrelevant
 Ask for TB
 Ask for autoimmune diseases

General appearance
 A= appearance
 B= built
 C= colors
 D= decubitus
 E= expression
 F= mental
 G= gait

General appearance (cont.)
 Vitals
 BP= low + orthostasis
 P
 Temp= night fever
 RR
 O2
 RBS= hypos
 UOP

 Upper limbs
 Lower limbs
 HEENT
 Trunk

 CNS
 CVS
 Chest= look for evidence of TB
 Heart
 Abdomen

General appearance
 The patient is ill looking and emaciated
 There is generalized pigmentation, more marked on the face, neck,
mucous membrane of the mouth, palmar crease, knuckles, knees
and elbows
 One vitiligo is present over the right thigh
•See the whole body (may be generalized
pigmentation).
•Face and neck (exposed parts).
•Mucous membrane of mouth (opposite the
molar), lips and conjunctiva.
•Skin crease (palmar crease), knuckles and
nipples.
•Pressure points (elbow and knee).
•Recent scar

 Sparse (or less) axillary and pubic hair
 No anemia, jaundice, cyanosis, clubbing, koilonychia, leukonychia,
edema
 Pulse—96/min
 BP—lying 100/60 mm Hg and standing 70/40 mm Hg.
SBP decrease by > 20 and DBP by > 10

 Abdomen
 Look for loss of pubic & axillary hair loss in 2ry AI
 Scar of previous operation

 Chest
 TB: apical crackles, bronchial breathing, cavity

Salient features
 Female
 Middle age
 Weight loss
 Postural hypotension
 Generalized pigmentation
 Amenorrhea for 4 months
 No TB
 No Steroids withdrawl
 Physical findings in examination

Presentation (cont.)

What are the diagnostic criteria in Addison’s
disease?
 Weakness or emaciation (100% cases)
 Pigmentation (90% cases)
 Hypotension (88%)

Q. What are the sites of pigmentation in Addison’s
disease?
 May be generalized
 Exposed parts (face, neck)
 Skin crease (palmar crease) and knuckles
 Pressure points (elbow, knee)
 Recent scar.

Why pigmentation?
 Due to increased ACTH (? POMC)

Why vitiligo?
 Autoimmune
 Vitiligo is present in 10 to 20% cases.

What are other causes of pigmentation?
 A. Physiological: familial, racial, pregnancy, prolonged exposure
to sun.
 B. Pathological:
Endocrine causes:
• Addison’s disease (brown or dark brown).
• Cushing’s syndrome.
• Acromegaly.
• Nelson’s syndrome (after bilateral adrenalectomy).
• Thyrotoxicosis.
• Ectopic ACTH syndrome.

What are other causes of pigmentation?
Infections: kala-azar.
Chronic liver disease:
• Haemochromatosis (greenish or bronze, less involvement of
mucous membrane).
• Cirrhosis of liver (common in PBC).
GIT: Malabsorption syndrome (Whipple’s disease, Peutz–Jeghers
syndrome)
Chronic debilitating illness:
• Internal malignancy (commonly ectopic ACTH syndrome),
CKD, any chronic illness.
Drugs: cytotoxic drugs, amiodarone

Why postural hypotension occurs in Addison’s
disease?
 It is due to hypovolemia and sodium loss.
 Mineralocorticoid deficiency is responsible for hypotension.

What are the common features absolutely found
in female?
 Loss of axillary and pubic hair (which is androgen dependent), as
androgens are produced only by adrenal cortex in female.
 This feature is not common in male, because androgen is secreted
from testes.

Mention one test to diagnose adrenal
hypofunction?
 Short synachten test.
OR
 8 AM cortisol + ACTH

What do you expect in Addison?
 Low serum cortisol & high ACTH

What are the diseases associated with Addison’s
disease?
 It is an autoimmune disease, may be associated with other
autoimmune diseases, such as Graves’ disease, Hashimoto’s
thyroiditis, pernicious anaemia, primary ovarian failure, myasthenia
gravis, type-1 DM.

How to differentiate between primary and secondary
adrenocortical insufficiency?

Final look

Cushing Syndrome

Personal
History
NAS OMRHH
• Age group
• Sex
• Marital status
• Habits = alchohol = pseudocushing
= smoking = lung cancer = ectopic CS

Chief
complaints
Excessive weight gain for … months
Weakness for … months
Backache and generalized body ache for
months
Skin changes, pigmentation, bleeding
spots
Hypertension

Chief
complaints
(cont.)
Psychiatric abnormalities e.g.
depression
Pathologic fracture (not related to
trauma)
Sexual dysfunctions: ED,
menstrual irregularities,
decreased libido

Present
history
• According to the statement of the patient,
she was reasonably well months back. Since
then, she is gaining weight which is
progressively increasing inspite of normal
food intake. She also feels extremely weak
and lethargic. The patient also complains of
backache and generalized bodyache for the
last … months. The pain is more marked with
activity and the patient feels comfortable by
taking rest.

Present
history
(cont.)
• Sometimes, she feels difficulty in standing
from sitting position. For the last … months,
she noticed multiple bleeding spots on the
skin, involving mostly the forearms and legs.
There is no history of headache, visual
problem, cough or chest pain.
• Her bowel and bladder habits are normal.
• There is no history of intolerance to cold, or
increased sleepiness.

Past history
Nothing significant
We need to exclude drug
history
Diseases treated with GC?
Alcohol = ? Pseudo-Cushing

Menstrual history
• She gives history of oligomenorrhea (or amenorrhea) for … months,
previously it was regular.

Family history
Irrelevant
Ask for similar conditions
Ask for obesity, hirsuitism
Ask for autoimmune diseases

General appearance
General overview:
Appearance
Built: overbuilt… or stunted growth in children
Color
Decubitus:
Exposure (Back, breast, genitalia)
Facial expression: moon facies, plethoric…
Gait: waddling in myopathy…

Vitals
• BP: HTN
• P
• Temp: fever = 2ry infection
• RR
• O2
• RBS
• UOP

General
appearance
(cont.)
Upper limbs: thin
Lower limbs: thin, bruises, thin skin
HEENT
Trunk: stria

• CNS:
Examine higher psychiatric
function e.g. psychosis
Examine motor system:
myopathy
Examine sensory system:
diabetic PN
• CVS
HTN complications
= LVE + LVF
• Chest
As a cause e.g. BA on GC, lung
cancer
As a sequel e.g. TB (cavity,
bronchial breath)
• Abdomen
Skin changes
Protruded abdomen
Abdominal mass
Examine genitalia

• Joint
Tender spine or bone = osteoporosis
Stunted growth
Deformity
Osteoarthritis
AVN of femur neck

General
appearance
(cont.)
• The patient is obese. There is more truncal
obesity with relatively lean and thin limbs
(lemon on a matchstick appearance)
• Face is moonlike, puffy and plethoric with
acne, hirsutism and frontal baldness

General
appearance
(cont.)
• There is buffalo hump at the root of the neck
and increased fat above both the
supraclavicular fossa
• There are multiple pink striae on abdomen,
back and axilla
• Skin is thin, with multiple purpura and bruise

Pulse—90/min, regular
BP—155/90 mm Hg
Temperature—37.2ºc
Respiration—16/min.

• Abdomen
 The abdomen looks distended and
flanks are full
 There are multiple pink striae of variable
size and shape
 No organomegaly
 Ascites—absent (as evidenced by absent
fluid thrill and shifting dullness)
• CVS
 Pulse—90/min
 BP—155/90 mm Hg
 Precordium—normal (look for
complication of HTN e.g. LVE, LVF)

• Chest
 TB: apical crackles, bronchial breathing
 Bronchogenic carcinoma: non resolving
pneumonia
• Nervous system
 Higher psychic functions—normal
 Cranial nerves—intact
 Motor system—proximal muscular
weakness of both upper and lower limbs.
 Reflexes are normal
 Sensory system– normal may be affected
in DM.

• Musculoskeletal System
Proximal myopathy is present more marked in the lower limb than
upper limb
There is slight kyphosis (osteoporosis)
Spine is tender at lumbar region (due to osteoporosis)
Stunted growth in children & adolescence

Salient features
Female
Middle age
Weight gain
Fatigue
Proximal weakness
Menstrual irregularity
Physical findings in examination

Different faces of Cushing
Obesity mostly
Cushing mostly
pituitary
Obesity + DM +
HTN mostly Cushing
mostly treatment
complications

What are the causes of puffy face?
• Cushing’s syndrome (plethoric moon
face, with hirsutism, acne)
• Myxedema (puffy with baggy eyelids,
fall of lateral eyebrows, malar flush)
• Nephrotic syndrome and acute
glomerulonephritis (puffy with
periorbital oedema)
• SVC obstruction (engorged and non
pulsatile veins, plethoric face with
subconjunctival effusion)
• Angioedema (localized, swollen lip or
face)
• Chronic alcoholism (plethoric, puffy
face)
• Simple obesity
• Surgical emphysema (history of
trauma, also swelling is extended upto
the neck and chest. There are multiple
crepitations on palpation).

What are the causes of periorbital edema
Nephrotic syndrome
Acute glomerulonephritis
Myxedema
Angioedema
Dermatomyositis
Orbital cellulitis
Malignant exophthalmos
Primary amyloidosis

Ecchymosis

What is the difference between Cushing’s
disease and Cushing’s syndrome?
CD= pituitary
ACTH-dependent
CS= syndrome of
hypercortisolemia

Other causes of stria?
• Striae gravidarum = stria nigra
• Cushing’s syndrome = stria rubra (wide lines, pink or purple or red,
mostly horizontal or oblique. Pink or red color is due to increased
vascularity).

How to differentiate clinically different types
of Cushing’s syndrome?
1. In Cushing’s syndrome due to adrenal cause:
 In adrenal adenoma—clinical features of glucocorticoid excess are
present but androgenic effect like hirsutism and virilisation are
absent and no pigmentation.
 In adrenal carcinoma—clinical features of glucocorticoid excess
are present and androgenic effect like hirsutism and virilisation are
rapidly progressive.

of Cushing’s syndrome? (cont.)
2. In ectopic ACTH syndrome—usually there is short history, excess
pigmentation due to high ACTH level, weight loss (rather than
obesity) and severe hypokalemic alkalosis. Hypertension and edema
are more common. Classical features of Cushing’s syndrome are
usually absent. Features of the primary lesion are present.
Marked hypoklemia suggests ectopic ACTH syndrome.

of Cushing’s syndrome? (cont.)
3. In Cushing’s disease—classic features of Cushing’s syndrome are
present. If there is pituitary macroadenoma, visual disturbance and
features of hypopituitarism may be present. There may be features
of raised intracranial pressure like headache.
4. History of alcoholism and depression or simple obesity suggests
pseudo-Cushing’s syndrome.

Final Look

Diabetes

Personal
History
N = Name
A = Age; to expect type of diabetes, but…
S = sex; determine sex specific complications
O = hazardous occupations e.g. risk of hypos
M = marital status; age of offspring
R = residence
H = habits of medical importance
H = handedness

Chief complaint
PAIN SWELLING DISTURBANCE OF
FUNCTION
+ Duration

Chief
complaints
Weight loss and weakness for
… months.
Excessive thirst and frequent
passage of urine for … months.
Burning sensation of the hands
and feet for … weeks.
Dimness of vision for …
months.

Present
history
Analysis of complain: Chronological order of symptoms,
mode of onset, their progression and course
Analysis of symptoms of the same system
Ask for associated symptoms
Investigations done (related to symptoms)
Treatment taken: e.g. replacement therapy or oral
contraceptives.

Present
History
• According to the statement of the patient, he
was alright … months back. Since then, he has
been suffering from gradual loss of weight,
about 12 kg, despite good appetite. It is
associated with extreme weakness and
excessive thirst for which he used to take plenty
of water every day. He also complains of
frequency of micturition, passage of large
volume of urine and waking up from sleep to
void.
• For the last … weeks, he has been experiencing
burning sensation, heaviness, tingling and
numbness of both hands and feet. His vision is
progressively deteriorating over the last …
months.

Present
history
(cont.)
There is no history of loss of consciousness
(diabetic ketoacidosis, hypoglycemia),
generalized swelling of body or legs
(nephropathy), chest pain (IHD), dizziness
or giddiness (postural hypotension) or any
skin abnormality (dermopathy, infection).
He denies any history of heat intolerance,
tremor (thyrotoxicosis), bowel abnormality
(malabsorption), cough, hemoptysis or
evening rise of temperature (TB).

Past history
• Drugs e.g. steroids
• Operations e.g. pancreatectomy
• Diseases e.g. thyrotoxicosis, or
inflammatory disease treated with
steroids.
• Also ask for drugs he take for diabetes
control

Family
History
• His father is diabetic for the last 25
years and his mother is
hypertensive.
• He has two brothers and one sister.
All of them are in good health.

Sexual History
Erectile dysfunction
Loss of libido
Dry ejaculation
Galactorrhea
Amenorrhea
Irregular menses
Uterine bleeding
Pregnancy history e.g. GDM
Menstrual History

General examination

Vital signs
Pulse
Blood
pressure
Respiratory
rate
Temperature
SO2 UOP RBG

General look
• A = appearance
• B = built
• C = colors
• D = decubitus
• E = facial expression
• F = mental status
• E = expose back and genitalia
• G = gait

Healthy versus ill

General
examination
(cont.)
• HEENT
• Upper and Lower limbs examination
• Systems examination
Chest
Heart
Abdomen
Neurological
MSK

• Ill looking and emaciated. (look for height, weight and BMI)
• There is no anemia, jaundice, clubbing, koilonychia, leukonychia or edema
• No thyromegaly or lymphadenopathy
• There is no ulceration or skin abnormality
• Pulse—96/min (look for peripheral pulses, may be feeble)
• BP—130/80 mm Hg lying and 125/80 mm Hg standing
• Temperature—98ºF
• Respiratory rate—14/min.

Systemic
examination

Nervous system
1. Higher psychic functions: Intact.
2. Cranial nerves: Intact.
3. Motor system:
 Muscle tone diminished in the lower limbs
 Muscle power is diminished, grade 3/ 5 in the lower limbs
 There is wasting of all the groups of muscle in the feet, legs and thighs.
 Reflexes

Nervous
system
(cont.)
Superficial reflexes (abdominal reflex)—
absent
Co-ordination—impaired in the lower
limbs
Romberg’s sign—positive
Gait—normal
Involuntary movement—absent.

Nervous system (cont.)
4. Sensory System
 Superficial sensation (pain, touch, temperature)—diminished in the foot up to mid
leg and hands (glove and stocking distribution)
 Deep sensation (vibration, position sense)—absent in both the lower limbs.
5. Cerebellar test: normal
6. Autonomic function: normal pulse, no postural dysfunctions
7. Fundoscopy: not done

Other
systems
• Examination of other systems reveals no
abnormalities.

What is your
diagnosis?
• My diagnosis is diabetes mellitus with
peripheral neuropathy with diabetic
retinopathy.

Related Questions &
Answers

What are the
criteria for
the diagnosis
of DM?
• Fasting plasma venous blood sugar level >
126 mg/dL (or 2 hour postprandial blood
sugar level 200 mg/dL).
• Random blood sugar > 200 mg/dL.
• During OGTT, > 200 mg/dL 2 hour after 75 g
glucose.
• Hb A1c > 6.5%

Remember the following points
• Random means without regard to time since the last meal
• Fasting means no calorie intake for 8 hours at least (not more than 16 hours)
• FBG (fasting blood glucose) < 100 mg/dL is normal
• In symptomatic patient, one abnormal finding is diagnostic of diabetes mellitus
• In asymptomatic patients, 2 values are required
• For OGTT, only fasting glucose and 2 hours after 75 glucose is sufficient for
diagnosis
• OGTT should be done only in borderline cases (fasting glucose 100 to 126 mg/dL
or random glucose 140 to 199 mg/dL) and also for the diagnosis of GDM.

Thyroid

Applied Anatomy
Parts of thyroid:
 2 lobes.
 Isthmus.
 ± Pyramidal lobe (in the
upper border of the
isthmus).

Applied Anatomy (cont.)
Each lobe measures:
 4 x 2.5 x 2 cm
Position:
 In the lower part of the neck
opposite C5,6,7 vertebrae.
 Muscular triangle.
 Apex paralel to oblique line of
thyroid cartilage.
 Base at level of 6th tracheal
ring.
 Isthmus lies opposite the 2nd,
3rd and 4th tracheal ring.

Capsule:
 True: from the CT of the
gland.
 False: from the pretracheal
fascia.

Lymphatic drainage:
 Peripheral part: Upper and
lower deep cervical LN.
 Medial parts of Lobes and
isthmus:
 1- Prelaryngeal and
pretracheal LN.
 2- Superior mediastinal LN.

Development
 The first endocrine gland to develop in the body at around 24 days
of gestation.
 It originates as proliferation of endodermal epithelium on the floor of
the developing pharynx.
 The foetal thyroid gland is connected to the tongue by the
thyroglossal duct, which subsequently solidifies and becomes
completely obliterated by 8–10 weeks of gestation.

Personal History
Personal: NAS OMRHH
 Age group.
 Sex.
 Occupation and Travel History.
 Marital status, menstrual, obstetric and sexual history.
 Residence: endemic areas away from sea???
 Smoking & GO

Complaint
Complaint + duration
 Pain: analysis as usual
 Swelling: analysis as usual
 Disturbance of function

History (cont.)
Disturbance of function
1- Symptoms of thyrotoxicosis:
- Unintentional weight loss.
- Hot intolerance.
- Excess sweating.
- CVS: palpitation.
- Resp: S.O.B.
- GIT: hyperdefecation.
- CNS: tremors, nervousness, insomnia.
- Bony ache.
- Genital: menstrual irregularitis, ED in males.

History (cont.)
Disturbance of function (cont.)
2- Symptoms of hypothyroidism:
- Weight gain: fail to loose weight.
- Bloated.
- Tiredness, loss of interest, poor memory.
- CVS: palpitation.
- Resp: S.O.B. (pleural effusion?)
- GIT: constipation, diarrhea?!.
- Bony ache.
- Genital: menstrual irregularitis, ED in males.

History (cont.)
3- Symptoms of malignancy:
- Rapid increase in goitre size
- Night fever, loss of weight and appetite.
- Local invasion symptoms.
- Remote mets symptoms.

History (cont.)
4- Pressure symptoms

History

Past History
 Drugs: cause thyroid disturbance or interfere with other.
 Operations: thyroid, neck.
 Irradiation: H & N irradiation.
 Other related illness: vitiligo, DM, pernicious anemia.

Family Hisotry
 Similarities.
 Autoimmune disorders.

Menstrual history
 Menorrhagia in toxicosis
 Amenorrhea in hypothyroidism

Obstetric history
 Possibility of postpartum thyroiditis

Examination (General)
Vital signs:
 Pulse (+ sleep pulse) (New onset AF).
 Temperature = increased with toxicosis
 Blood pressure= wide pulse in toxicosis, diastolic HTN in
myxedema
 Respiratory rate.

General overview:
 Appearance= looks…
 Built: under built…
 Color
 Decubitus: HF?
 Exposure (Back, breast, genitalia)
 Facial expression: starring look…
 Gait: waddling in myopathy…

Head to toe examination:
 HEENT (Neck and thyroid)
 Upper limb
 Lower limbs

Other systems screening:
 CVS: sinus tachy, Lerman scratch, flow murmur.
 Chest: metastasis to chest wall, mediastinal syndrome
 Neurologic: neuropathy, myopathy
 Abdomen: organomegaly.
 Back

Eye examination:
 Naffziger test.
 Russel Frazer test.
 Ruler test.
 Hertel’s exophthalmometer.

Nafziger test
 Eyeball is protruded
beyond plane of
supraciliary ridge

Russel Frazer test
 From side
 Eye lightly closed
 Determine the depth of
the groove between
orbital margin and
covered globe

When the distance from the lateral orbital margin to the front of the cornea
exceeds18mm,exophthalmos is present

Hertel’s exophthalmometer

Special eye signs:
 Stellwag sign: infrequent blinking, serpentine look
 Dalrymple sign: upper eye lid retraction
 Mobius sign: impairment of ocular convergence
 Joffroy sign: lack of forehead wrinkles
 von Graefe’s sign: lid lag of upper eyelid
 Griffith sign: lid lag of lower eyelid
 Rosenbach sign: eyelid tremor on fine closure
 Topolanski sign: congestion of pericorneal region
 Jellinek sign: upper eyelid folds are hyperpigmented
 Tellas sign: brownish pigmentation of lower eye lid

Thyroid examination
General rules
 Don’t strangle your patient.
 Don’t press so much (if you press, you miss).
 Swallow is the magic word.
 Normally the thyroid gland is neither visible nor palpable.

Thyroid examination (cont.)
A- Inspection: from front and sides.
 Swallow.
 Assess scar asymmetry or masses.
B- Palpation.
 Assess lobes and isthmus (search pyramidal lobe)
 Don’t forget LN++ - Perry’s sign of absent carotid.
C- Percussion.
 For retrosternal goitre or superior mediastinal LN.
D- Auscultation.
 For bruit, stridor?
E- Special test.
 Pemperton test. - Kocher test of tracheomalacia
 Deglutition test. - Tongue protrusion test.

Thyroid examination (cont.)
A- Inspection: from front and sides.
 Proper exposure & position
 If a goitre, ask the patient to swallow a mouthful of water. The
thyroid moves up with swallowing.
 Assess for scars, asymmetry, or masses.
 Watch for the appearance of any nodule (not visible before
swallowing) beware that, in an elderly patient with kyphosis, the
thyroid may be partially retrosternal.

Characters of thyromegaly
 Thyroid enlargement causes swelling in the neck which encroaches
the suprasternal notch and tries to obliterate it.
 The swelling moves with deglutition.

Inspection

Inspection (cont.)

Palpation

Palpation (cont

Palpation (cont.)

Palpation (cont.)
 Note the size, shape, temperature, tenderness, consistency,
nodularity and fixation of the thyroid swelling
 Goitre is soft in Grave’s disease, firm in Hashimoto’s thyroiditis and
hard in thyroid malignancy and Riedel’s thyroiditis.
 Thyroid tenderness is seen in thyroiditis.
 Thyroid temperature is raised in Grave’s disease, multinodular
goitre.

Percussion

Ausculatation
 Tell patient to hold breath

Don’t forget trachea

Special tests
1- Pemperton sign

Special tests (cont.)
2- Kocher test

Special tests (cont.)
3- Tongue protrusion test

Email: usamaragab@medicine.zu.edu.eg
Slideshare: https://www.slideshare.net/dr4spring/
Mobile: 00201000035863

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