Clinical Endocrinology Round
By Dr. Usama Ragab Youssif
Lecturer of Medicine
Zagazig University
Acromegaly
Cushing
Diabetes
Thyroid
Addison
Techniques and clinical insights
Bulbar palsy refers to impairment of function of the cranial nerves IX, X, XI and XII, which occurs due to a lower motor neuron lesion either at nuclear or fascicular level in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.
Bulbar palsy refers to impairment of function of the cranial nerves IX, X, XI and XII, which occurs due to a lower motor neuron lesion either at nuclear or fascicular level in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docxpbilly1
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
The current presentation is regarding history taking skill of a physician and general physical examination of a patient, intended for improving the clinical approach of 1st year BAMS students from a Physiology and Pathological point of view.
SOAP NotePatient Initials RA Pt. Encounter Number .docxpbilly1
SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother: Alive, Htn
Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool
EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11 years LMP: 09/15/20 G 0 T 0 P 0 A 0 L 0 Birth Control/Type: NoneMenopause: no Sexually Active: yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion
BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.
Symptoms and Signs of different Diseases in UrologyAbdullah Mohammad
How would you approach a Urological Patient? This presentation will tell you how to take a history and examination along with symptoms and common signs of different diseases in urology
Diabetic Peripheral Neuropathy and Vitamin B12 IssueUsama Ragab
Diabetic Peripheral Neuropathy and Vitamin B12 Issue
By Dr. Usama Ragab Youssif
Diabetic neuropathies are the most prevalent chronic complications of diabetes
Central and Peripheral Precocious PubertyUsama Ragab
Precocious Puberty
By Dr. Usama Ragab Youssif
Precocious puberty (PP) is defined as the development of pubertal changes (2ry sexual characters), at an age younger than the accepted lower limits for age of onset of puberty.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docxpbilly1
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
The current presentation is regarding history taking skill of a physician and general physical examination of a patient, intended for improving the clinical approach of 1st year BAMS students from a Physiology and Pathological point of view.
SOAP NotePatient Initials RA Pt. Encounter Number .docxpbilly1
SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother: Alive, Htn
Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool
EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11 years LMP: 09/15/20 G 0 T 0 P 0 A 0 L 0 Birth Control/Type: NoneMenopause: no Sexually Active: yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion
BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.
Symptoms and Signs of different Diseases in UrologyAbdullah Mohammad
How would you approach a Urological Patient? This presentation will tell you how to take a history and examination along with symptoms and common signs of different diseases in urology
Diabetic Peripheral Neuropathy and Vitamin B12 IssueUsama Ragab
Diabetic Peripheral Neuropathy and Vitamin B12 Issue
By Dr. Usama Ragab Youssif
Diabetic neuropathies are the most prevalent chronic complications of diabetes
Central and Peripheral Precocious PubertyUsama Ragab
Precocious Puberty
By Dr. Usama Ragab Youssif
Precocious puberty (PP) is defined as the development of pubertal changes (2ry sexual characters), at an age younger than the accepted lower limits for age of onset of puberty.
Algorithms for Diabetes Management for StudentsUsama Ragab
Algorithms for Diabetes Management for Students
By Usama Ragab Youssif
Lecturer of Medicine - Zagazig University
Agenda
Type 2 Diabetes 101
Incretin based therapy
Algorithms of management
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Classification & Diagnosis of Diabetes.pptx
By Dr. Usama Ragab Youssif
Lecturer of Internal Medicine Zagazig University
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Renal System - History Taking
By Dr. Usama Ragab Youssif
Lecturer of Medicine, Zagazig University
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Functional Bowel Disorders
By Dr. Usama Ragab
Esophageal Disorders
Gastroduodenal Disorders
Bowel disorders
Centrally Mediated Disorders of GI Pain
Gallbladder and Sphincter of Oddi Disorders
Anorectal disorders
Childhood Functional GI Disorders: Neonate/Toddler
Childhood Functional GI Disorders: Child/Adolescent
Heat, Cold and High Altitude Related illnessUsama Ragab
Heat, Cold and High Altitude Related illness
By Dr Usama Ragab
Lecturer of Medicine
Topics are heat and cold related illness and high altitude medical disorders
Imeglimin, What is new?
By Dr. Usama Ragab Youssif
Lecturer of Medicine - Zagazig University
Agenda
Mitochondrial function and dysfunction
Mitochondrial (dys)function in diabetes
Diabetes core defects and Imeglimin
Imeglimin drug development and approval
Imeglimin and Heart
Diabetes and Gut interplay
By Dr. Usama Ragab Youssif
In Gastro Canal Association Annual Conference
Agenda
Diabetes as the main player
Gut as the main player
Diabetes and gut in a separate game
Gut as game changer
Tips and tricks: diabetes drugs
Guidelines in Obesity management
By Dr. Usama Ragab Youssif
Obesity-related counseling should be offered to those with BMI ≥25 kg/m2
A 3% to 5% weight loss can result in meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes
Set an initial weight loss goal of 5% to 10% of current body weight over 6 mo
After 6 mo, focus on weight maintenance before attempting further weight loss
Participating in a weight loss program long-term can help improve weight maintenance
Intensification Options after basal Insulin RevisitedUsama Ragab
Intensification Options revisited
By Dr. Usama Ragab Youssif
Add an OAD
Add a short-acting insulin at mealtime
Switch to premixed insulins
Novel insulin combinations
Basal insulin/GLP-1 RA combinations
Insulin Lispro Revisited
By Dr. Usama Ragab Youssif
The discovery of insulin was one of the most dramatic and important milestones in medicine - a Nobel Prize-winning moment in science.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
3. Personal History
N
A = gigantism versus acromegaly
S = male (macroadenoma) versus female (microadenoma)
O
M = married or divorced
R
H
H
Dr. Usama Ragab Youssif
5. 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.
Dr. Usama Ragab Youssif
6. 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.
Dr. Usama Ragab Youssif
7. 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.
Dr. Usama Ragab Youssif
8. Present history
General = sweating + heat or cold intolerance + appetite
CVS = symptoms of HF, HTN….
Chest =
NS = central or peripheral +/- psychiatric
GIT = polypi
Dr. Usama Ragab Youssif
9. 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.
Dr. Usama Ragab Youssif
10. 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.
Dr. Usama Ragab Youssif
11. Past History
Drugs
Operation: previous surgery or radiation
Disease
Dr. Usama Ragab Youssif
12. Family history
DM or any other endocrinal or autoimmune disease.
Similar condition in the family = familial acromegaly
Dr. Usama Ragab Youssif
13. 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
Dr. Usama Ragab Youssif
14. General examination
Vital signs General overview
Pulse
BP
Temperature
Respiratory rate
Appearance
Built
Color
Decubitus
Exposure: back & genitalia
Facial expression
Gait
Mental
Dr. Usama Ragab Youssif
16. 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.
Dr. Usama Ragab Youssif
17. 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
Dr. Usama Ragab Youssif
18. 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
Dr. Usama Ragab Youssif
20. Genitalia & breasts
Look genitalia for hyper or hypogonadism
Virilisation
Breast development, atrophy and galactorrhoea.
Dr. Usama Ragab Youssif
21. 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
Dr. Usama Ragab Youssif
23. 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
Dr. Usama Ragab Youssif
24. 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)
Dr. Usama Ragab Youssif
25. 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.
Dr. Usama Ragab Youssif
26. 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.
Dr. Usama Ragab Youssif
27. 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.
Dr. Usama Ragab Youssif
30. 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.
Dr. Usama Ragab Youssif
31. What are the causes of prominent supraorbital
ridge?
Rickets
Paget's disease
Achrondroplasia
Hydrocephalus
Hereditary hemolytic anemia.
Dr. Usama Ragab Youssif
32. What are the causes of macroglossia?
Acromegaly
Hypothyroidism
Amyloidosis
Down's syndrome.
Dr. Usama Ragab Youssif
33. You are in the examination theatre
Dr. Usama Ragab Youssif
34. 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’.
Dr. Usama Ragab Youssif
35. 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).
Dr. Usama Ragab Youssif
36. 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.
Dr. Usama Ragab Youssif
39. 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.
Dr. Usama Ragab Youssif
40. 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?
Dr. Usama Ragab Youssif
41. 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.
Dr. Usama Ragab Youssif
42. 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.
Dr. Usama Ragab Youssif
43. 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?
Dr. Usama Ragab Youssif
49. General appearance (cont.)
CNS
CVS
Chest= look for evidence of TB
Heart
Abdomen
Dr. Usama Ragab Youssif
50. 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
Dr. Usama Ragab Youssif
51. General appearance (cont.)
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
Dr. Usama Ragab Youssif
52. Systemic examination
Abdomen
Look for loss of pubic & axillary hair loss in 2ry AI
Scar of previous operation
Dr. Usama Ragab Youssif
54. Salient features
Female
Middle age
Weight loss
Postural hypotension
Generalized pigmentation
Amenorrhea for 4 months
No TB
No Steroids withdrawl
Physical findings in examination
Dr. Usama Ragab Youssif
61. What are the diagnostic criteria in Addison’s
disease?
Weakness or emaciation (100% cases)
Pigmentation (90% cases)
Hypotension (88%)
Dr. Usama Ragab Youssif
62. 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.
Dr. Usama Ragab Youssif
65. 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.
Dr. Usama Ragab Youssif
66. 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
Dr. Usama Ragab Youssif
67. Why postural hypotension occurs in Addison’s
disease?
It is due to hypovolemia and sodium loss.
Mineralocorticoid deficiency is responsible for hypotension.
Dr. Usama Ragab Youssif
68. 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.
Dr. Usama Ragab Youssif
69. Mention one test to diagnose adrenal
hypofunction?
Short synachten test.
OR
8 AM cortisol + ACTH
Dr. Usama Ragab Youssif
70. What do you expect in Addison?
Low serum cortisol & high ACTH
Dr. Usama Ragab Youssif
71. 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.
Dr. Usama Ragab Youssif
72. How to differentiate between primary and secondary
adrenocortical insufficiency?
Dr. Usama Ragab Youssif
75. Personal
History
NAS OMRHH
• Age group
• Sex
• Marital status
• Habits = alchohol = pseudocushing
= smoking = lung cancer = ectopic CS
Dr. Usama Ragab Youssif
76. Chief
complaints
Excessive weight gain for … months
Weakness for … months
Backache and generalized body ache for
months
Skin changes, pigmentation, bleeding
spots
Hypertension
Dr. Usama Ragab Youssif
78. 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.
Dr. Usama Ragab Youssif
79. 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.
Dr. Usama Ragab Youssif
80. Past history
Nothing significant
We need to exclude drug
history
Diseases treated with GC?
Alcohol = ? Pseudo-Cushing
Dr. Usama Ragab Youssif
81. Menstrual history
• She gives history of oligomenorrhea (or amenorrhea) for … months,
previously it was regular.
Dr. Usama Ragab Youssif
82. Family history
Irrelevant
Ask for similar conditions
Ask for obesity, hirsuitism
Ask for autoimmune diseases
Dr. Usama Ragab Youssif
83. 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…
Dr. Usama Ragab Youssif
86. Systemic examination
• 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
Dr. Usama Ragab Youssif
87. Systemic examination
• Joint
Tender spine or bone = osteoporosis
Stunted growth
Deformity
Osteoarthritis
AVN of femur neck
Dr. Usama Ragab Youssif
88. 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
Dr. Usama Ragab Youssif
89. 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
Dr. Usama Ragab Youssif
91. Systemic examination
• 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)
Dr. Usama Ragab Youssif
92. Systemic examination (cont.)
• 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.
Dr. Usama Ragab Youssif
93. Systemic examination (cont.)
• 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
Dr. Usama Ragab Youssif
98. 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).
Dr. Usama Ragab Youssif
99. What are the causes of periorbital edema
Nephrotic syndrome
Acute glomerulonephritis
Myxedema
Angioedema
Dermatomyositis
Orbital cellulitis
Malignant exophthalmos
Primary amyloidosis
Dr. Usama Ragab Youssif
105. What is the difference between Cushing’s
disease and Cushing’s syndrome?
CD= pituitary
ACTH-dependent
CS= syndrome of
hypercortisolemia
Dr. Usama Ragab Youssif
106. 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).
Dr. Usama Ragab Youssif
107. 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.
Dr. Usama Ragab Youssif
108. How to differentiate clinically different types
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.
Dr. Usama Ragab Youssif
109. How to differentiate clinically different types
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.
Dr. Usama Ragab Youssif
113. 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
Dr. Usama Ragab Youssif
115. 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.
Dr. Usama Ragab Youssif
116. 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.
Dr. Usama Ragab Youssif
117. 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.
Dr. Usama Ragab Youssif
118. 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).
Dr. Usama Ragab Youssif
119. 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
Dr. Usama Ragab Youssif
120. 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.
Dr. Usama Ragab Youssif
121. Sexual History
Erectile dysfunction
Loss of libido
Dry ejaculation
Galactorrhea
Amenorrhea
Irregular menses
Uterine bleeding
Pregnancy history e.g. GDM
Menstrual History
Dr. Usama Ragab Youssif
124. General look
• A = appearance
• B = built
• C = colors
• D = decubitus
• E = facial expression
• F = mental status
• E = expose back and genitalia
• G = gait
Dr. Usama Ragab Youssif
135. • 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.
Dr. Usama Ragab Youssif
137. 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
Dr. Usama Ragab Youssif
139. 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
Dr. Usama Ragab Youssif
143. 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%
Dr. Usama Ragab Youssif
144. 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.
Dr. Usama Ragab Youssif
146. Applied Anatomy
Parts of thyroid:
2 lobes.
Isthmus.
± Pyramidal lobe (in the
upper border of the
isthmus).
Dr. Usama Ragab Youssif
147. 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.
Dr. Usama Ragab Youssif
150. Applied Anatomy (cont.)
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.
Dr. Usama Ragab Youssif
151. 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.
Dr. Usama Ragab Youssif
152. 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
Dr. Usama Ragab Youssif
153. Complaint
Complaint + duration
Pain: analysis as usual
Swelling: analysis as usual
Disturbance of function
Dr. Usama Ragab Youssif
154. 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.
Dr. Usama Ragab Youssif
155. 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.
Dr. Usama Ragab Youssif
156. History (cont.)
Disturbance of function (cont.)
3- Symptoms of malignancy:
- Rapid increase in goitre size
- Night fever, loss of weight and appetite.
- Local invasion symptoms.
- Remote mets symptoms.
Dr. Usama Ragab Youssif
159. Past History
Drugs: cause thyroid disturbance or interfere with other.
Operations: thyroid, neck.
Irradiation: H & N irradiation.
Other related illness: vitiligo, DM, pernicious anemia.
Dr. Usama Ragab Youssif
174. Nafziger test
Eyeball is protruded
beyond plane of
supraciliary ridge
Dr. Usama Ragab Youssif
175. Russel Frazer test
From side
Eye lightly closed
Determine the depth of
the groove between
orbital margin and
covered globe
Dr. Usama Ragab Youssif
176. When the distance from the lateral orbital margin to the front of the cornea
exceeds18mm,exophthalmos is present
Dr. Usama Ragab Youssif
178. Examination (General)
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
Dr. Usama Ragab Youssif
182. 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.
Dr. Usama Ragab Youssif
183. 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.
Dr. Usama Ragab Youssif
184. 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.
Dr. Usama Ragab Youssif
185. 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.
Dr. Usama Ragab Youssif
194. 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.
Dr. Usama Ragab Youssif
The striae in CS are red-purple in color and usually greater than 1 cm in width , (in contrast to silver, healedpost-partum striae)
Fundoscopy may revel few dot and blot hemorrhages in the 6 o’clock position, 2 disc diameter away from the optic disc in the right eye. Few dot hemorrhages in 10 o’clock position, 1 disc diameter away from the optic disc.
Attachment of pretracheal fascia
Above: oblique line of thyroid cartilage & hyoid bone
Below: superior mediastinum
On each side: carotid sheath
Abnormalities of developmentRemnants of the thyroglossal duct may be found in any position along the course of the tract of its descent:
In the tongue, it is referred to as ‘lingual thyroid’.
Thyroglossal cysts may be visible as midline swellings in the neck.
Thyroglossal fistula develops as an opening in the middle of the neck.
As thyroglossal nodules or
The ‘pyramidal lobe’, a structure contiguous with the thyroid isthmus which extends upwards.
The gland can descend too far down to reach the anterior mediastinum.
Pain= OCD, ↑, ↓, associated symptoms, chch, site, radiation, relation to meals, exertion, position
Swelling= OCD, site, number, associated other swelling as LNs mets
Trachea: dyspnea
Esophagus: dysphagia
Sympathetic chain: Horner’s syndrome
RLN: hoarsness of voice
Carotid artery: fainting attacks
IJV: edema of the eyelid
Remember TRH & prolactin
BMI <18 kg/m2
Plummer nail= distal separation of nail plate from nail bed
Thyroid acropachy
The Means-Lerman scratch is a mid-systolic murmur heard in the setting of a hyperthyroid state at the left upper sternal border and end-expiration. This is thought to occur from rubbing of the pericardium against the the pleura in the high output, hyperdynamic states of hyperthyroidism and may sound similar to a pericardial friction rub as seen in pericarditis.
When the distance from the lateral orbital margin to the front of the cornea exceeds18mm,exophthalmos is present
When the distance from the lateral orbital margin to the front of the cornea exceeds 18mm, exophthalmos is present
FIGURES 20.5A and B Inspection of thyroid: (A) Note the huge enlargement of thyroid with the obliteration of supraclavicular fossa. There is exophthalmos with visible sclera both above and below the cornea; (B) Pizzalo’s method of demonstration of mild enlargement of thyroid