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1. THE ENDOCRINE SYSTEM
HISTORY AND EXAMINATION

5. THE THYROID

7. EXAMINATION OF THYROID GLAND
Inspection
Sometimes the isthmus of the normal thyroid is visible as
a
diffuse central swelling in the neck. Enlargement of the
gland,
called a goitre, should be apparent on inspection.
1. Look at the front and sides of the neck and decide
whether
there is localised or general swelling of the gland.
2. Then ask the patient to swallow a sip of water while
you
watch the swelling. Only a goitre or a thyroglossal cyst
will
rise during swallowing, because of their attachment to the
larynx.
3. Ask the patient to stick out his or her tongue: a

8. EXAMINATION OF THYROID GLAND
Palpation
1. Systematically feel both lobes of the gland and its
isthmus
from behind the patient using the tips of your fingers.
Note the size, shape, consistency, symmetry,
tenderness and mobility of the gland and the presence
of a
thrill. Decide whether the lower limit of the gland is
palpable.
2. Ask the patient to swallow and feel for the swelling to
rise.
3. Feel next for the cervical lymph nodes

9. EXAMINATION OF THYROID GLAND
Percussion
1. Percuss over the upper sternum. Dullness may indicate
a
retrosternal goitre.
2. Test for Pemberton’s sign. Ask the patient to lift up
both
arms as high as possible. In thoracic inlet obstruction
(e.g. by a retrosternal goitre), the patient’s face will turn
red, cyanosis will occur, the neck veins will swell and
stridor (harsh inspiration caused by a partly occluded
upper airway) may occur.

10. EXAMINATION OF THYROID GLAND
Auscultation
1. Auscultate over the gland. A soft bruit
may be audible when an overactive
gland is very vascular.
2. Listen to the patient’s breathing for
stridor.
3. If there is a goitre, apply mild
compression to the lateral
lobes and listen again for stridor.

11. HISTORY SUGGESTING HYPERTHYROIDISM
Ask about:
• fatigue, poor sleep
• tremor, heat intolerance, excessive
sweating (hyperhidrosis)
• pruritus (itch), onycholysis
(loosening of the nails from the
nail bed), hair loss
• irritability, anxiety, emotional
lability
• dyspnoea, palpitations, ankle
swelling
• weight loss, hyperphagia, faecal
frequency, diarrhoea
• proximal muscle weakness
(difficulty rising from sitting or
bathing)
• oligomenorrhoea or amenorrhoea
(infrequent or ceased
menses, respectively)
• eye symptoms: ‘grittiness’,
excessive tearing, retro-orbital
pain, eyelid swelling or erythema,
blurred vision or diplopia
(these symptoms of
ophthalmopathy occur in the setting
of autoimmune thyroid disease).

12. HISTORY SUGGESTING HYPOTHYROIDISM
Ask about:
• fatigue, mental slowing, depression
• cold intolerance
• weight gain, constipation
• symptoms of carpal tunnel syndrome
• dry skin or hair.

15. TESTING ANKLE JERKS. THIS METHOD BEST DEMONSTRATES THE
‘HUNG UP’ REFLEXES OF HYPOTHYROIDISM.
LOOK FOR RAPID DORSIFLEXION FOLLOWED BY SLOW PLANTAR FLEXION AFT ER THE
TENDON IS TAPPED.

16. THE PARATHYROIDS
Ask about:
• polyuria, polydipsia (hypercalcaemia)
• abdominal pain or constipation (hypercalcaemia)
• confusion or psychiatric symptoms (hypercalcaemia)
• bone pain (hypercalcaemia)
• muscle cramps, perioral or peripheral paraesthesia
(hypocalcaemia).

19. THE ADRENALS

22. THE ENDOCRINE SYSTEM:
A SYSTEMATIC APPROACH
1. Pick up the patient’s hands. Look at
their overall size (increased in
acromegaly—excess growth hormone)
and for abnormalities of the nails
(hyperthyroidism and hypothyroidism).
2. Take the patient’s pulse (thyroid
disease) and blood pressure
(hypertension in Cushing’s syndrome
(glucocorticoid excess) or postural
hypotension in Addison’s disease
(adrenocortical hypofunction).

23. THE ENDOCRINE SYSTEM:
A SYSTEMATIC APPROACH
3. Look for Trousseau’s sign (tetany from
hypocalcaemia in
hypoparathyroidism). Inflate the blood pressure
cuff
above systolic and wait 2 minutes: if positive, the
thumb
becomes adducted and the fingers extended.
4. Go to the axillae. Look for loss of axillary hair
(pituitary
failure: pan-hypopituitarism) or acanthosis
nigricans and
skin tags (acromegaly).

24. THE ENDOCRINE SYSTEM:
A SYSTEMATIC APPROACH
5. Examine the patient’s eyes (hyperthyroidism)
and the
fundi (diabetes mellitus). Look at the face for
hirsutism or
fine-wrinkled hairless skin (pan-hypopituitarism).
Note
any skin greasiness, acne or plethora (Cushing’s
Syndrome)
6. Look at the mouth for protrusion of the chin
and
enlargement of the tongue (acromegaly) or
buccal pigmentation (Addison’s disease).

25. THE ENDOCRINE SYSTEM:
A SYSTEMATIC APPROACH
7. Examine the neck for thyroid enlargement. Palpate
for
supraclavicular fat pads (Cushing’s syndrome).
8. Inspect the chest wall for hirsutism or loss of
body hair,
reduction in breast size in women (pan-
hypopituitarism).
Look for gynaecomastia in men (e.g. testicular
failure,
thyrotoxicosis). Look for nipple pigmentation
(Addison’s
disease).

26. THE ENDOCRINE SYSTEM:
A SYSTEMATIC APPROACH
9. Examine the abdomen for hirsutism, central fat
deposition and purple striae (Cushing’s syndrome).
10. Look at the legs for diabetic changes, including: •
loss of peripheral pulses • signs of limb ischaemia •
peripheral neuropathy • Charcot’s joints • arterial
ulcers • necrobiosis lipoidica diabeticorum • insulin
injection sites • fat atrophy.
11. Test the urine (diabetes mellitus).

27. QUESTIONS?