BCC / Clinical Consultation NLT

ENDOCRINOLOGY

1) Hyperthyroidism
- Neck swelling / Vision problem / Weight loss / Palpitation / Loose motion / HTN / Vitiligo / AP$
2) Hypothyroidism
- Weight gain / Fatigue or tiredness / Fatigue & sleepiness (OSA) / Hand pain (CT$) / Proximal myopathy
3) Hyperparathyroidism
- Hypercalcaemia / Polyuria / Renal stones / MEN
4) Pseudohypoparathyroidism
- Short stature / Tetany / Tingling of limbs
4) Cushing syndrome
- Weight gain / Proximal myopathy / Fatigue / Hypertension / Dizziness or Faint (withdrawl)
5) Addison’s disease
- Dizziness or Faint / Weight loss / Abd: pain & vomiting / Fatigue or tiredness / AP$
6) Hypopituitarism – Sheehan’s $ / Post-viper bite / Autoimmune
- Fatigue or tiredness / Dizziness or faint
7) Pituitary tumour – Prolactinoma / Acromegaly / Non-functioning tumor
- Prolactinoma – HA / Abnormal vision / Menstrual problem / Nipple discharge
- Acromegaly – HA / Abnormal vision / Face change or pain / Hypertension / Joint pain
Fatigue & sleepiness (OSA) / Hand pain (CT$)
- Non-functioning tumor - HA / Abnormal vision
8) Pheochromcytoma
- Palpitation / HA / Weight loss / Hypertension
9) Diabetes mellitus – Cause / Complication / Association
- Uncontrolled DM – HH
- DM with visual loss / DM with blackout or faint / DM with weight loss / DM with loose motion /
Hypoglycaemia / AP$
10) PCOS
- Weight gain / Hirsutism
11) Autoimmune polyglandular $ - DM / Addison / Thyroid
12) MEN – 1 or 2

APPROACH
1) Short stature
2) Weight gain
3) Weight loss
4) Hypoglycaemia
5) Fatigue
6) Gynaecomastia
7) Hirsutism

APPROACH TO ENDOCRINE PROBLEMS

- Introduction
- Look at a glance to patient for spot diagnosis
- Focus history
- C/O
- SOCRATES - Asso: - weight
- Background history – past, drug, family, personal
- Focus examination
- Primary site - *for prompt & diagnosis
- Others - Face, Limbs, Relevant system
- Concern
BCC / Clinical Consultation NLT
CAUSES OF A SHORT ADULT INCLUDE
Genetic
Familial (correlation between a patient’s height and the mid-parental height)
Achondroplasia (?short limbs, relatively normal trunk, large head with bulging forehead and scooped nose)
Turner’s $ (?webbed neck, cubitus valgus, short metacarpals, female phenotype, left-sided heart lesions)
Noonan’s syndrome (?triangular micrognathic facial appearance and posteriorly angulated low-set ears with
a thick helix, webbed neck, shield-like chest, pectus excavatum, cubitus valgus, mental retardation,
right-sided cardiovascular abnormalities)
Growth hormone deficiency
Nutritional or general diseases during childhood
Low birth weight and subsequent slow growth (some cases end up as short adults)
Congenital heart disease (?cyanosis, young adult)

1 Child looks normal

(a) Normal growth velocity:
- Constitutional delay in growth and adolescence (common; short throughout childhood; pubertal growth
spurt delayed; bone age lags behind chronological age; patients usually attain normal height)
(b) Low growth velocity:
- Thin child (mostly due to a disease of a major system):
Central nervous system (mental retardation)
Cardiovascular system (congenital heart disease)
Respiratory system (cystic fibrosis, asthma, TB)
Gastrointestinal system (malabsorption, e.g. coeliac disease, Crohn’s)
Renal system (chronic renal failure, renal tubular acidosis)
Psychosocial problems (emotional deprivation, anorexia nervosa)
- Fat child (endocrine causes):
Hypopituitarism
Growth hormone deficiency†
Laron’s $ (same phenotype as growth hormone deficiency but cause is somatomedin deficiency –
resting growth hormone levels are high; no response to growth hormone therapy)
Hypothyroidism
Cushing’s
Pseudohypoparathyroidism
2 Child looks abnormal
(a) Dysmorphic features:
- recognizable syndrome (e.g. low birth weight, chromosomal abnormality)
(b) Disproportionate short stature:
- Short limbs (e.g. achondroplasia, hypochondroplasia, dyschondrosteosis, metaphyseal chondroplasia,
Multiple epiphyseal dysplasia)
- Short back and limbs (e.g. metatrophic dwarf, spondyloepiphyseal dysplasia, mucopolysaccharidosis)

CAUSES OF WEIGHT LOSS

- Appetite good
Hyperthyroid Endocrine
DM Malabsorption
Pheochromocytoma
Malabsorption Chronic illness / infection
- Appetite loss Malignancy
Malignancy Psychiatric illness
Chronic illness
Addison
- Intentional weight loss
Anorexia nervosa
BCC / Clinical Consultation NLT

CAUSES OF WEIGHT GAIN

Endocrine
1) Cushing’s $
2) Hypothyroid
3) Insulinoma
4) PCOS
5) Acromegaly
6) Pseudohypoparathyroidism
Pregnancy
Drugs
Depression
Simple obesity

CAUSES OF HYPOGLYCAEMIA
Fasting hypoglycaemia
In diabetic - Treatment, Diet, Exercise, Alcohol
Complications – Nephropathy, Gastroparesis
Associated diseases – Addison’s disease / APL$ (Type 1 DM) / Coeliac

In non-diabetic - EXPLAIN
Exogenous drugs, eg insulin, oral hypoglycaemics.
Diabetic in the family)? Body-builders may misuse insulin to help stamina.
Also: alcohol, eg a binge with no food; aspirin poisoning; ACE-I; beta-blockers; pentamidine;
quinine sulfate; aminoglutethamide; insulin-like growth factor.
Pituitary insufficiency.
Liver failure, plus some rare inherited enzyme defects.
Addison’s disease.
Islet cell tumours (insulinoma) and immune hypoglycaemia (eg anti-insulin receptor antibodies)
Non-pancreatic neoplasms, eg fibrosarcomas and haem angiopericytomas.
Post-prandial hypoglycaemia
May occur after gastric/bariatric surgery (‘dumping’), and in type 2 DM

CAUSES OF POLYURIA / THIRST

1) Diabetes mellitus
2) Diabetes insipidus
Cranial
Nephrogenic
3) Hypercalcemia
4) Psychogenic polydipsia
5) Early CRF
6) Drugs – Lithium, Demeclocycline
Diuretics

CAUSES OF FATIGUE / LETHARGY

1) Endocrine
- Hypothyroid
- Cushing’s $
- Addison’s disease
- Hypopituitarism
- DM
2) Rheumatology
- CTD
- Vasculitis - Takayasu
- PMR
3) Anaemia
BCC / Clinical Consultation NLT
4) Malignancy
5) Chronic illness / infection
6) Chronic fatigue $ / Depression
7) Others – MG, PBC, OSA, Pregnancy

CAUSES OF GYNAECOMASTIA
Physiological
Pubertal (very common, often unilateral – due to transient dominance of circulating oestradiol over
testosterone)
Senile (normal rise in oestrogens and fall in androgens with age)
Pathological
Cirrhosis of the liver (?stigmata)
Tumour
Carcinoma of the lung (5% of patients; due to HCG secretion, sometimes with HPOA)
Carcinoma of the liver (HCG secreting)
Testicular tumours (due to HCG secretion, oestrogen secretion)
Adrenal carcinoma (due to oestrogen secretion)
Testicular failure
Klinefelter’s syndrome (47,XXY, small testes, mental deficiency, incomplete virilization, raised LH and
FSH and can have tall stature)
Kallman’s syndrome (Isolated gonadotrophin deficiency – hypogonadotrophic hypogonadism and
anosmia, often with harelip or cleft palate)
Pituitary disease i.e. acromegaly, hypopituitarism (?visual field defect)
Thyrotoxicosis (?exophthalmos, goitre)
Addison’s disease (?pigmentation – buccal and scar)
Drug induced
Hormonal Oestrogens
Aromatizable androgens (e.g. testosterone enanthate, testosterone propionate)
Antiandrogens (cyproterone acetate)
Cardiac Calcium-channel blockers, Angiotensin-converting enzyme inhibitors, Digoxin, Amiodarone,
Spironolactone, Methyldopa
CNS Dopamine receptor antagonists (phenothiazines, metoclopramide), Tricyclic antidepressants,
Benzodiazepines, Opiates, Marijuana
GI Omeprazole, Cimetidine, Ranitidine
Anti-infec: Isoniazid, Metronidazole, Ketoconazole
Cytotoxic Alkylating agents (cause testicular damage) such as busulphan and nitrosureas
Alcohol

CAUSES OF HIRSUTISM
Androgen secretion by the ovary
Polycystic ovarian syndrome,
Hormone producing ovarian tumour
Androgen secretion by the adrenal gland
Late-onset congenital adrenal hyperplasia
Cushing’s syndrome
Drugs
Steroids, Phenytoin, Cyclosporin, Minoxidil, Diazoxide
Others
Pregnancy, Familial
BCC / Clinical Consultation NLT