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    Macleod's Clinical Examination Endocrine system

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    Macleod's Clinical Examination Endocrine system

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    74 views17 pages

    TOTO

    Uploaded by

    Raed Abu Hamad
    Macleod's Clinical Examination Endocrine system

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    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 17
    Anna R Dover Nicola Zammitt ee ad pysloy 198 The ist 188 ineon pest sions 19 ist ends, up fan and sc is 190 ‘he pysicl examination 197 Sil earn 197 Tye gna 97 e198 tery ad pyply 108 Te istry 198 Cannery ston 16 at ve, du fly asc toy 198 The pyscal extn 190 ae ‘atopy and pysoy 200 Toe sory 20 | Camnen reseing srs 200, Famine 200| ‘Te pyle examination 200, The endocrine system ‘aatony an pysioeg 201 Tre isory 201 ‘Sonean pong tas 20, Pat al ae eg sn 202 ‘Tae pein eamination 212 ‘Ao and physi 204 “heist 204 Caran pase sys 204 ‘ny and pyseion 25 “oer 205 ‘neon peg ots 200 slic ei ad en no 200, ‘Tha phi exariraton 206 ‘0606 orange 1 Neck ewolng 208 (080e Earpe 2 Diabet et 208 FP Kew My 4 26 B22h= 38 pees Pee @D tO 394 » THE ENDOCRINE SYSTEM Endocrine glands syrihesise hormones that are leased into the cicuston end act at distant sos. Diseases may resut ftom ex0assive oF inadequate hormone production, oF target ‘exgan hypersenatvty or resstance tothe hormone. The main ferdocine glands are the pitstary, thycid, adrenals, gonads {testes and ovaries}, perathyrods and the endocrine pancreas. ‘Wit tha notable exception ofthe pancreatic iet cols (ich raloace inguin) and the parathyrods, most endocine glands fae themselves contolod ky homones relaased from the Since hormones chelate traughout the body. symptcms and signs of endoctine dsoaae are frequently nor-spacife, afactng rary body systems (Box 10.1). Ofen, endoctine dense is poked up inecontally during biochomca eating or adological ‘maging, Carell histery taking and examination ae requred 10 recognise Charactastic pattems of disease, Thyroid fseese and tdabotes mala ee cornmon ane! quent fami: establishing ‘a dele fami hater is thatfore important. Some less corren lendoctne eborcars (52h as mule endocrine neoplesis) show pitty ‘an autogerral dominant pattem of itiance. ae ee Te ae - Se A Symptom ign or problom. Dierentaliagoses Treress yeeros, rgpenhrodiam dbaes mls peparsn ah gn paid, POOS, Cus’ syactone Weg oss Theyre, debtes malts, atonal wali Dasthoe peter, past rodcing tro, caro ise nek nen Sipe goire, eves’ dase, Hshict's Uys Pala cease ts ‘Dibeas mas, debees rasa, peparatyaisn, Con's score Fisasn inate, POU, congenial abel ypepas, Custings scone Fueny uo eo Typopheaena,pheashrmioagions,neuoendoaire unou ‘Beeotg inetldsn, yppooadisn cineca, chaaorvonecyira Fusing pono Gepealy menopauce) coca score estan paranson Gonns snctome,Gutig’s scone, slasectronocans, exonenaly “aneroniee/olgamerorhoea 7006, perrelasiecamia,Hyié dytrction roa dstancton Primary a secondary hpogiradeon, Sees nous, no echonte Stamic seve, medication ndeod| (es, ba tocar, cites) Mae wean Cushing's androm, hporiraldan, ypemaraiyciden,csconatca one rag ad acres Theopmedsm, hygertradiom, Chg’ syne, primary pepe FEU, go nga “The thyroid is a buterly-shaped gland that fos infeior to the ‘rood cartlage, approximately 4 cm below the superior notch ofthe thyroid cartiaga (Fig, 10.1). The normal thyroid has @ \olums of <20 ml. and is paizablein about 0% of women and 25% of men, is comprised ofa central isthmus approsimately 415 em wide, covering the second to four tracheal rings, anc two ‘eteral abe that are usualy no larger than tha sta phan ‘of the pabert's thumb. The gend may extond ino the superior rmackastinum and cen be parly or enialy retrostema. Rarely, it ‘canbe located highain the nec along the tne of Ine Uyrogbssel duct, en exrbxyologca remnant of the descent of the thyroid from the base of the tongue fo its final postion. Thyrogiossal ‘ots canals av for te thyogiossal duct: they often occur athe level ofthe hyeld tone (9. 10.1) and characterstoaly Tree upwvarcs on tongue presi. The thyroid is altacnad! to the pretrachoa! ascie and thus maves superoly cn swallowing or nock extension. “Tyrotorccss is acca state increased metabofsm caused by dvatet eetatig lvls thycld honmones. Graver’ cease is be most common cause (Fig. 102 and Box 10.2) ie an auiormmune dsease wth a fara component arc! Is 5-10 times more commen ia woren, usualy presenting batween 30 and 50 years of age, Other causes include toa muitindular Qo, soltary tox node, hyroktis and excessive thyroid hormone ingestion. Hypottyroldim is caused by reduced levels of thyroid hormones, usualy cue to autoimmune Hashimoto's thycit, and affects women approximataly six times more common then men, Most other ceuses are intogenic and include previous ractolocine therapy 0 surgery for Graves" disease. Common presenting symptoms — [pNeck swotting Gola i enlargement of the thyroid gland (ig. 10.9). kis not eceseariy apocitod with thycid dystunetion ane most patients . ‘The history * 195 ot bore Sternadidorestod ———-—F nuke j| ‘Thy cattoge ‘Gicat means = "bea erage —=—-—— Lebo oh ps ans Paayeoe Isthmus of ty gland ——_——— Tethes Marubum of sora A 8 Fig 101 The thyroid land] Act of tbe gan ans sounding stsies. (Paoli the thr and fom bai, Fig. 102 Graves’ hyperthyotis [Epes (B] Saver tarry ty ee bese, (E} Tyidaeroacty [Bret mposdes wi gat a shyt Large eosteal ents aya. | occ nodes: hi ary ae fund ry cn ecko eee otha etaing sts, ans or | chest agra Sree “rte maybe soy Fe, 1030) omy rset ab ao tetin tbr suntan gerd Papsbereases | ELN@CK pain acento i Oe were aa | Neck pa b uncommon nd Gee anon ee ee Soko para hae | oret and asoeed wh ry erat, My Terea 4190 « THE ENDOCRINE SYSTEM Fp. 103 Thyroid enlargement [E]*Ttretiam racers scan demnstraig use gnve duet Graves’ done, (B] use ge de © teas cenat [6 slay tic ned [B] *"Tecnoen cadence sean conning male gpte and} Cauley fOr Dip Pa being into an enlsting thyroid rode. Pein can also cocur in viral subacute (de Queries) tyros. [i] History suggesting hyperthyroidism Ask about: * fatigue, poor sleep + esmer, heat ntlerence, excessive sweating (hyperhicross) + prurtue (ch, onycholyss Goosering ofthe nals from te al bed, hai loss intatity, avety, emotoral lebilty ‘yspnoee, palptatios, erie sweling ‘weightloss, hyperphagia, fsecal frequency, darthoea ronal muscle weekress (dfculy rising rom sting or bathing) + ofgornenarthooa or amenorihoea (nfrecuant or ceased menses, respective + eye sympions:‘gitiness’, exosscve tang, rero-orbitsl pa, eyed sveing or enthams, biured vision or ciolap's fihese symptoms of ophthalmopathy cocur inthe seting of autoimmune tnyrold ciseasel, {History suggesting hypothyroidism ask about + fatigue, mental slowng, depression cold intolerance weight gain, constipation symptoms oF carpal tunnel syndrome dry akin or hair. eae ees oe etary + Fede + Pete peta enn men 5 Fan isa tt ob aan cease 5 uot gprs Cotes eos in, perrl waicd Phys exinaton — 5 yt act + bis yo nme cn be aa + od ot 5 rel moe rele aptly reo, ees, ona) Past medical, drug, family and social history ak about ‘prior nack Fracaton {fk factor for thyroid malin + recent prograncy (postpartum thyrotis usually conus i the fest 12 months) = chug therapy: enithyrod druge or raloiodine therapy ‘amiodarone and ithicen can cause ytd dystunction + farilybistory ef thyroid o° othr autcimemune disease ‘+ resderoe in an area of iodine dsficenoy, such as tho ‘Andae, Halayas, Ceriral Afoa: can cause gotre and, revely, bypothyraidimm + smnoking fnereanes the rok of Graven’ ophthalmopathy General examination Look for signs of walght loss or gain (calauate the body mass ince, and assess the patient's be! restlessness, apathy oF slowed movements. Patonts abrormal spoech (pressure of speech suggests hyporthyroissm, wwnie speach Is oflen sow and daso in hypothyroicis), Hoerseness ia suggestive of vocal cord paralysis anc should ‘aise euspcion of thyroid malignancy, Features oftypertyrcidism and hypothciien on exertion ve sumimarged in Fg. 10.4 Features of thyrotoncosi include warm, moist skin, prose muscle wealmess (due to @ catabolic energy state) tremor ‘ard brisk dsp tendon retles, Hyperthyroigsn mey also be ‘associated wih tachyrdia oration, and a syste Cardiac tow murmur due Io increased cardiac output “Thyroid sccopachy fs ah extrathyroidal marifestetion of utoinenune thyroid diseaea, tis characterised by sofstssue ‘Sweling and peiostel hypertrophy ofthe dtl ohalangss, anc ries finger elublng (98 Fe. 10.20), Ris ten associated with emepsy and ophihamepaty, Peni myxcedema aed, tscoloured (usualy irk oF brown} indurated appearance over the antarior shins; dagplte ts ner, t's speclicaly associated with Gravee" disease ars nat nypoyroidsn (98 Fig, 1.20), os oe ‘Galt ita bitin 4 Huy velee ‘ras dase) ‘yor waa i i pt pate an capt vate a Salim Lane Hecoragia Praia ygpaty epaiee ovation (Gras seas) le sring— tnteaitanee) ae oneal * Lewmelbote rae + Weghtes dsgte > west gan incesed appa + Dry skin andres + Heatslearee + Senay focal * Ary tly * Latargy ental + Fa fe emer ‘patent, depression Fig. 104 Festres of nypr- and hypothyroidism ‘The physical examination © 197 Many clinical features of hypothyroidism are produced by rmyroedema (non-piting oadema caused by tissue intraticn bby mucopolysacehardes, chondkotin and hyalurorie aio; Figs 104 and 10.5}. Other commen frngs in kypotyreicksm inclode gore, co9h cy or ares en, bradycaris,deayod ankle retlaes| and a slowing of movernent quia + Caer the facil appearance, nating sins of ry or coatee ha and peirbtal pufnass (Fig. 10.5) 1 Inspect the nands far ilign, thyroid acrapacty, onyeholsle and paknar entherna + Assess the pulse (tachycerda, atl fain, bradycaraa end blood pressure + Avscuitale he eat fora micsystolic fae rmusmur trypethyroiion). + Inspect the lbs for coarse, dry skin end pretibial rysoederna + Asg036 proximal muscle power and deep tendon (ark) reflexes ip. 129) Thyroid gland 20% fom the front, noting any asymmetry oF scars, nspeet the trod forn the sid withthe patients neck sightly extended. Exiending the neck wil cause the ‘thyreid (and trachea} to ge by afew centimetres endl may make the gland mote apparent. Gve the patent a gess of later an’ ask therm fo lake a sip and then swat. The thyroid rises (it the trachea) on swallowing ' Pabate the thyroid by placing your hanes gentiy onthe front ofthe neck with your index igre just touching. ‘he standing bering the patlant (see Fi. 10.18). The patient's neck should ba light faxed to relax the Fig, 105 Type facies in hypestyroidsm. 498 © THE ENDOCRINE SYSTEM slemacleidomestoid muacien, Ask th pationt to swalow again ane ea the gland as it roves upwards, + Note the size, shapa and consistency of ary goire and fee fr ary the © Palpate fr cervical lmphadenopathy (se Fa. 3.27). © Borcuss the manutrium to assess for duhness Cue to fetrosleral extension of gotta, + Aupcutate with your stethoscope for a thyroid bruit. A thyroid brut ometmes associated with palpable thal) inciostee abnormally high bloed fow and is most ‘commonly associated with Graves” disease. Mt may be ‘confuses wth cther sounds: bruls for the carotid artery ‘or those transit from the aorta are louder along the fre of the artery. Early sirple goles ae atively symmetice but mey boom cular wth time, in Graves’ clsease the surface of the tyro is ‘sully emooth an dius; in uninodisr or mutinodler goire itis regula (see Fig. 103), Difuse tendemess is typical of vial thyroiits, Lecalised tenderness may fatow bleeding info & fyi yet. Fain ofthe tyro to surounding sires (320% that It dogs rot move on swailoning) end associated conical Iymehadanncamy ievesse the tkshood of thyroid malignancy. Furthor investigation of thyroid clsoccers Ie summarised in Box 103. Eyes + Look fr virial pufnass or o2dema, anc Kd retraction (bis i present the white scar is vise ‘above the isn the primary postion of gaze; see Fig. 10-20) + Examine for features of Graves’ ophtnakopatiy, lasing ‘exophthalmos dook down ror above and behed the patio, Id gweting or extrema, and conjunctival redress ‘ swaling (chemo + Assess for i lag: ask the patient to follow your dex fnger as you move i tron the upper to the lower car of ‘he vival fil. Us lag means delay between the movement of the eyeball and descent ofthe upper eyelid, ‘exposing the sciera above the is. ‘There ore wously four parathyroid glands stusted posterior ta the thyrld (988 Fig. 10.1A), Each is about the size of a pes and produces paratryrld Hormone, a peptide tht increases, crcting calcium levels ‘Common presenting symptoms Perathyoidcisoaso i commonly asymetomatc. a hypeparaty= roids the most common symptoms relate to hypercsleaemia: ee vestigation indian eonment Biochemisty | Tia onlin tests Toasess tho sate Tmmanology tld proses abodes Non-peii, high atom yc disease tty stmultng more Spel fr Sve! donee cy artes ‘imaging terms aie, nodule “Thyra storapty (Te) To asses areas of gor ‘ype Compas moet ‘To ass ole sized id sa lang Tvasivratior Freseete aston ology Thod nadla Respaioy Sordume ngps To assess ache comproson frre a ge pate + Asvess eye movements (ee Fi. 8.11). Graves’ ‘ophinalmopaty is characterstoaly associated with reatction of upgaze. Lic retraction fa stag appearance due to widening of the palpebral fesire) enc Id log [68 exer) are corrmon eye signs ‘associated with hyparthyradism. Both are thought to be due To contiction ofthe levator muscles ao a result cf sympathetic Pyperactivly, Pesotital pufiness (myxoedems} is sometimes 900 fn Fypothyroicsm, Graves” apithaimopathy occure in around 20% of patients snd is caused by an inlammmatoy infittion of the soft teauss tnd extraocular muscles (cea Fig, 10.22). Features suggestive of active infemmation Inlude spontaneous or gaze-evoked tye pal, and redhess oF swellng of the Ids or conjunctive. Proptosi (rotsion ofthe globe with respect tothe obit} may ‘cocur in both active and inactive Graves’ ophthsimapaty and isolten referred to as exophthalmos, iamnaton a the ofits soft tissues may lead to other more severe features, ining cermeatuloeration, diplopia, ophihaimoplagia and compressive optic neuracaihy (se6 Fg. 8.80). aS polyria, plyéesa, eral stones, panic uceration, tender areas of bane fracture cr deformity (Brown tumours’ Fg. 10.64), and deliv or psychlati symptoms. In Hypopsrathyreigm, hypocelcsemia may osuse hyper-selinéa or tetany (ivokantary ‘muscle contraction), most commonly in the hands or feet. Paraosthesae ofthe hands and fet or around the mouth may ‘cour. Hypopavethyroais ks most often caused by inadvertent damage to the glands during tyro surgery but may aiso be caused by autcimmune date Petont withthe rae eutosomal ‘dominant condi pseudchypocerathyroidsm have end-organ restance to perahyrd hormone and ypicalyheve shot stature, @ round feoe end shertening ofthe fourth and fith metacarpal ‘bones fg. 1.68.0). ‘The physical examination + 199 Fe eping vith Brown tut (A Cotes of DO Patt ‘Ask about polutis, plyipsiafrypercaloseih domi! pain or constipation (hypercalcasi) contusion or psychiatric symptoms frypercatoasmi) bone pain hypercalcasria) rust cramps, priotal or pacpherel paraesthesia (hypoosicaemn) Past medical, drug, family an social history : Ask about + recent ack surgery or iadation + past History of bone fractures + peat History of ronal stones 1 family History of hyperparatyricism (which con be part of the autosomal dominant muliple endocrine neoplasia syndrome} or other endocrine disease (Aison's disease and type 1 dabetes can be associted with rypoperatyroidism as part ofthe autosomal recessive type 1 autoimmune poanciiar syndrome). Hands: ask the pata to rake a fst and assess the tength ofthe matacarple (n peoudahypoparatnyrocism the motacarpals ofthe ring and Ite fingers are shortened Fg, 10.680) Fig 106 Parathyroid cas [i] tet nt en lh song rs wa ted [B Paulohyeeaatyeiin so furan Mh raps, [6] These ae best seen when the patent makes 2H of he thd metcepal othe ht a are, Fig. 107 Troussenu's sgn. Examine the neck for scars, Parathyroid tumours re very revaly palpable, Measure the blood pressure and aseoss the state of hydration (p, 244), Infating the bleed pressure cult ln a patient wi hypocelcaernia may preciptate cxpal ‘muscle contraction, produning atypical picture wth the thumb adduced, the proximal interchaiangeel and Gstl rtarphalangeal joints extended and the rretacerpophalangest ints fexed (main accouareur, hand ofthe obstercen, or Trausssau's sign: Fa, 10.7, “Tout fr muscle weakness and hyper-refenia(p, 128). Look fr evidence of recent fractures or tone defer cenerness. Prior urinals fenal stones may ees in baematuia 200 + THE ENDOCRINE SYSTEM “The pitutery land is enloved inthe seta turcica at the base of tie sll beneath the hypothalamus. tis bridged over by fold ot dura mate (aaphragra sel) withthe sphencial sinus below tnd the optic chasm above. Lateral othe pity fossa are the ‘cavernous sinuses, conning eran! nerves fl IV and Vi and the ‘ternal carotid eteren, The glad compiss anterior an pctoror Iobes. The anterior obe secretes adrenocorticotrephie hormone (CT, prolactin, growth hornone (GH), thyric-stimalating hortrone (TSH and gonadotrophins futsinising hormone (LH) and foic-etimulating hormone (SH). The posterer lobe ie fan extension of the hypothalamus, and secretes vasopressin {arvisuretic hormone) and oxytocin Common presenting symptoms Prtiary tumours ave cernman ard are found incidental in srouns 10% of patients uncergeing head computed tomography (GT) oF rmagnstiorescnenice Imaging (MF. Mypoptutasism can result froma spece-vocupying sin or Fora dostructhe rire ‘process such as trauma, acotherany, sarcoidosis, tubereuosis ‘br malesttic disease, Ptutary warction or haernorthage can result in acute byporitutariom (ferred to as puitary apopieny) senoiisa medical emergency; hs oten associated wth headacte, ‘ortng, eu impeiment and altered consciousness. Non-functioring pituitary adenomas mey ba asymptomatic or may prasent th local elect, such 2s compression of the ‘optic chiaem causing viusl 1oss fypicaly btempcral upper | ‘quadrantancpia of hemanopia; Fi. 10.8 and see Fig. 85) Fig, 108 Pitutary macroedenoma, The tunou extend it he ‘suas em and cessing the oe cis, Coven of | Dr Diy Pate, or headache cue to expansion of the sefe. Adenomas may produne hetrenes such as peolacte, GH or ACTH; he esuling Symptoms and signe wil depend on the excess hormone present [f Protactinoma Ask about: + galactounoee (beast mk section) + cigomenortheee, smenorinova or inert (mn women + resuced tbo, erectile dysfunction and reduced shaving frequency fr men} j Acromegaly GH excess porto puberty presente as gigas ster puberty, ‘causes acromegay. Ak about: + headache + excessive sweating ‘+ changea i facial fatures (ask to see okt photographs) «+ anincraase in shoe, ring or glove size + associated medical condions: ertnropathy, carpal tunnet scram, hyperiension, diabetes, ooloie maignenoy, slaep apnoes. {Ltypopituitarism ‘apart rom headache das to stretching of the claphragma seliae and visuel aonoxmaltes, clrical presentation depends on the efcency of the spect anterior pitutary onones invohed, Ireiidual cr multiple hormones may be volved, so questioning in relation to deficiencies of the thyroid, adrenocortical and ‘eprodutive hormanes is noeded. Family history Enguie about family history since ptitery ieessa con ocour es part of innented mise endocrine neopiasia ox fil latory syndromes. skin, prominent oupraoretal idges, enlargement ofthe ‘086, prognatiam {protrusion ofthe ance) and separation ofthe loner teeth Fig. 10.98) + Enamin the hands end teot for sot-issue enlargement and tight-fiting ings or shoes, carpal tunnel syndrome and arthropatty Fig. 10:80.0) + Azooee the voual fields (9. 162). + Check the blood pressure and perform urinalysis Hyperlension and cabelas mvs are common associations, The history © 201 Fig, 10 Aeromagay [Tce laces. (B)Prgrathism ad spaton ofthe tweet, [B) Lr, testy bands (] Witoiog of te feo JL Hypopituitarism + sent anllry heir Fig, 10.108) * reduced/abeent seconde sexual nat and testicular ‘trophy (eau2ed by goradoitohin dlicioney) ++ veual field defects (mast oflen biternpora hemionopie), Look for: pte atroohy or cranial rarve defect il, IV and Vi, «+ exteme sn par (@ combination of rid ansernia and ‘caused by @ tumour compressing the opte chasm, opti rmelenenyte-simuating hormone deficiency, Fig. 10.108) petve oF cavernous sinus. “The actensis ere smal, pyramidal organs lying immediately zl 7 sbove the kidneys on ther posteromedial surface. The adrenal | Common presenting symptoms ‘modula ie part of the sympathetic nervous system and couretes catecholamines. The acronel cortex sscretee corte) | Cushing's syrutome is caused by excess exogenous oF {@ gucacorivoia, minarakocoriccids and androgens. endogenous gucecerteold exposure. Mast cases are lato 202 © THE ENDOCRINE SYSTEM ‘9, 10:10 Hypopltutarism.[] pooh cused by 0 pity anor (ete, al shi [Aon allay at, genic and caused by side effects of glucecertcoid therapy. "Endogenous Quehing's usualy results fiom an AGTH-eseretins pituitary microadenoma, but otner causes inchde a primary fadienal tumour oF ‘ectopic! ACTH sonretion by @ tumour, The ‘catabolic affects of glucocorticoids cause widespread tissue breakdown (eacing to proximal myopathy, tagity fractures, sponiangous bnising and akin thinning) and central ecoumaton | Df body fat Fa. 10°11), Patients ray develop hypertension or Gabetes and are suscepibe to infection. Hypertension can aso resul fom overproduction of aldosterone (a rinerdacortioa ‘or catecholarines (Box 10.4) -Aaclson's csease Is de to inadequate secretion of cortisol, usually secondary to autcimmure destruction of the adrenal cortex. Symptoms are usualy non-epecic (ope ater ‘Acrenal adenomas usualy eresent wit features of hormone hypersecretion, as desorbed later. Occasional, they mey be ‘asymptomatic ond ore detected icidentaly on abdominal CT ‘or MAI scans. Functcning adteral adenomas may present with refraciry hypertension Box 10.9, [Cushing's syndrome ‘Ask about + ncrease in weight, peti f tho weight s centrally cdstiouted + bruising, voleosous striae and sin thinning + ffouly sing from a chakdbath (mey indicate pox ‘ryopaty) ff Addison's disease Ask obout + weakness + pootural ightheedodhass + navsee, vomiting, danhoea, constipation, abdominal pin and weight loss ‘+ rmuacie ramps. Past medical and drug history Enquire about recent or past exogenous gtucocoriid usage (routs, do80, duration) ae his may contro to ether iatrogenic Cushing's erdrame or uprescion cf tho hypothaariititary- ‘adeanal axis and resutant guoccoticoid insutcincy. EE Look atthe face and general appesrance for central ‘beat; there may be a round, plethors ‘moon! face Fig. 10,114) or doecoonioal ist pad (butte hutro. + Examine the skin for thinning and bruising (10.110), striae (eapeciay abdominal Fig, 10.110), acne, hirsutism an ‘ne of ffection or poor wound healing, ‘+ Measure the blood pressure, ‘Examine the lags for proximal muscle weakness and edema. + Perform ophthakmoscony for catarects and hypertensive ratial changes (800 Fe. 8.1). + Perform urnelysis for shoosur. Ue aS Ba ‘The physical examination * 203 ig, 111 Cushing's syndrome. (A) Cushing faces (B] ne uate pian age. [Tal etre: ail oun ad plato, cnt hey, tol muse wath an vlocoue ein sie [B] Skin hie: pupa cases by wrswech presse. E SO ee Consion eerie! nous bekil ete Cassio Ae Tl Cag rene Sai cei iy, na ay Fas wa es, Sng es sap er ee saaie entre) 204» THE ENDOCRINE SYSTEM + Look for signs of weightloss. { eamine the shin for abnormal cx excessive pigmentation, ‘Thsis mest prominantin sun-exposed areas o ith subject lo au or pressure: skin creases, buccal mucosa (Fig, 10.128) anc racem sears. ln primary adreret ‘The gonads (lestes and overs) eaccote sex hormones [estesterone and oestrogen) in response to gonadotrophin [FSH and LH oleae by the citutary. The reroductve system is covered in Chapter 11 ‘Common presenting symptoms Moat carnmanly, mon present with ancrogen datlancy whereas |women present with hyperandrogerism, ‘ypoganaciem car ba primary (alle ofthe gonad di) oF secondary hers reduced gonadotrophin levels cause gonadal | insutcieney, the pituitary incresses ACTH eooretion in response 19 fon cortisol Ives, High aves of AGTH increase ‘relanooyt-

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