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Endocrine for Finals (OSCE orientated)

Endocrine for Finals (OSCE orientated). Dr Joe Littlechild and Dr Emma Salter FY1. Past Manchester Endocrine Stations. Examine endocrine status – Cushing’s Examine endocrine status – Acromegaly Examine feet – diabetic foot ulcer/Charcot’s

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Endocrine for Finals (OSCE orientated)

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  1. Endocrine for Finals (OSCE orientated) Dr Joe Littlechild and Dr Emma Salter FY1

  2. Past Manchester Endocrine Stations • Examine endocrine status – Cushing’s • Examine endocrine status – Acromegaly • Examine feet – diabetic foot ulcer/Charcot’s • Neck examination – goitre +/- thyroid status evident • Ethics – DM wants viagra on NHS • Ethics – DM driving...need to inform license and DVLA

  3. Cushing’s • Acromegaly • Thyroid • Diabetes • All other endocrinology comes up in MCQs - PasTest

  4. The Thyroid W.I.P.E.R. ‘Wash hands, introduce, permission, expose, reposition’

  5. Examination Part 1: Thyroid/Neck lump • A) Inspect • B) Palpate • C) Percuss • D) Auscultate • Special test: Pemberton’s

  6. Inspection • Front and sides • any scarring • Position • midline, anterior/posterior triangle (sternocleidomastoid divides them) • Swallowing • Ask patient to take sip of water (thyroid moves upwards) • Stick tongue out • Thyroglossal cyst moves upwards

  7. Ddx Neck lump • Midline • Goitre • Thyroglossal cyst • Dilatation along thyroglossal duct; fixed to hyoid bone  tongue protrusion moves it • Anterior triangle • Branchial cyst • Lie anterior to upper 3rd of the SCM, 66% present on left, typically present in 3rd decade • Carotid body tumour • Next to hyoid bone ant to SCM, red-brown appearance, angiography shows splaying of carotid bifurcation, affects people in their 50s • Lymph node • Posterior triangle • Cystic hygroma(above clavicle) • Can be large, lymphatic malformation, children <2 years old • Lymph node • Anywhere • Sebaceous cyst • lipoma

  8. Palpate • ‘Have you any pain in your neck?’ • Stand behind, using both hands • Size/shape/symmetry • Diffuse/nodular • Fluctuance (‘slip sign’ – lipoma) • Pulsation (carotid body tumour) • Can you get below the swelling  if no, then think retrosternal goitre • Transilluminate lump: neck cyst  thyroglossal, branchial, hygroma • Palpate for nodes – have a routine

  9. Ddx goitre • Multinodulargoitre • Most common large goitre • Can be smooth rather than multinodular to feel • Usually euythroid = non-toxic • Hyperthyroid= toxic • Indications for surgery in non-toxic  cosmetic/local compression • Grave’s disease • Solitary nodule (adenoma/carcinoma) • Hashimoto’s thyroiditis • Subacute thyroiditis

  10. Palpate • Have you any pain in your neck?’ • Stand behind, using both hands • Size/shape/symmetry • Diffuse/nodular • Fluctuance (‘slip sign’ – lipoma) • Pulsation (carotid body tumour) • Can you get below the swelling  if no, then think retrosternal goitre • Transilluminate lump: neck cyst  thyroglossal, branchial, hygroma • Palpate for nodes – have a routine

  11. Palpate nodes

  12. ..And the rest • Percuss sternum from xiphy up to suprasternal notch  retrosternal goitre • Auscultate lump  bruit is diagnostic of Grave’s

  13. Special test • Pemberton’s test: obstructed venous return from head • slowly raise both arms above head… watch for facial plethora

  14. Ddx Hyperthyroidism • Grave’s (90%) • Hyperthyroidism • Goitre – usually smooth • Eye signs (75%) • Exophthalmos • Ophthalmoplegia • Acropachy • Pre-tibialmyxoedema • TSH-receptor antibodies • Toxic MNG – usually nodular • Toxic adenoma 99%

  15. Ddx hypothyroidism • Iatrogenic (90%) • Post-iodine therapy • Post-thyroidectomy • Post radiotherapy • Drugs • Carbimazole: used to treat hyperthyroidism to block TPO enzyme • Amiodarone: used in Rx AF; contains iodine and can cause hyper/hypo • Lithium: mood stabiliser in bipolar • Idiopathic • Autoimmune inc Hashimoto’s • Iodine deficiency – number 1 cause worldwide • Secondary - hypopituitarism

  16. Examination Part 2: Thyroid status • General inspection • Thin, fidgety, sweaty, restless = hyperthyroid • Fat, warmly dressed, hair loss, dry skin, deep voice = hypothyroid • Hands & wrist • Acropachy (clubbing) • Hot, sweaty or cold, dry palms • Palmar erythema (hyper) • Tremor (hyper) • Pulse (AF in hyper) • Phalen’s test  Carpal tunnel syndrome (hypo) • Face • Limbs

  17. Face • Facial appearance – flushed/peaches n cream • Hair/eyebrows – thin, brittle or non-existent • Eyes • Unique to Grave’s: exophthalmos & ophthalmoplegia • Eyelids – lid retraction in hyper/ puffy in hypo • Eye movements • Look for espupgazeophthalmoplegia (Grave’s) • Lid lag • Stand in front if patient • “Follow my finger, keep your head still” • Move finger upwards so you see lids retract • QUICKLY move finger downwards – look for lid lag

  18. Limbs and the rest • Reflexes – knee/biceps… brisk or slow-relaxing (hypo) • Tinel/Phalen’s test positive in hypo • Proximal myopathy: shoulder ABduction • Stand from chair with arms crossed (HYPER) • Oedema • Pre-tibialmyxoedema – GRAVE’s • Generalised non-pitting peripheral oedema HYPO • CONCLUDING REMARKS • TFTs, USS, FNA

  19. Hyperthyroidism treatment • Medical • Symptomatic control: beta-blockers • Anti-thyroid therapy: carbimazole • Radioiodine • CI in pregnancy/breast feeding, if young children at home • Surgical (cosmetic, compression, malignancy) • (Sub)Total thyroidectomy • Complications: • Early: Anaesthetic/haemorrhage/infection • Damage to surrounding structures – recurrent laryngeal nerve, trache, oesophagus, neck musculature • Late • Hypoparathyroidism • Recurrent hyperthyroidism • hypothyroidsim

  20. Please examine this patient’s endocrine system. You may ask a few questions to help you come to a diagnosis • Cushing’s • Acromegaly

  21. Cushing’s Syndrome • Chronic glucocorticoid excess

  22. Cushing’s syndrome • ACTH dependent (aka increased ACTH) • ACTH independent

  23. ACTH dependent • Cushing’s disease - Pituitary adenoma causing bilateral adrenal hyperplasia • Ectopic ACTH release - Small cell lung cancer • Carcinoid tumours • Ectopic CRF production (rare)

  24. ACTH Independent(reduced ACTH due to –ve feedback) • Iatrogenic steroid use • Adrenal adenoma/carcinoma • Adrenal nodular hyperplasia

  25. Cushing’s Examination • General Inspection • Hands • Arms • Face incl visual fields • Neck • Abdomen • Proximal muscles • Extras

  26. General Inspection

  27. Hands • Look for bruising • Compare skin folds (thinning)

  28. Arms • Brusing • Thinning of skin • Blood pressure

  29. Face • General inspection – characteristic rounding of the face • Greasy skin • Facial plethora • Acne • Hirsutism

  30. Abdomen • Increased central body habitus • Purple abdominal striae • Renal transplant scar

  31. Extras • Proximal muscles – arm abduction - stand from chair with arms crossed • Feel back for spinal tenderness, interscapular fat pad • Visual fields – rare in cushing’s

  32. Offer • Check U+E – hypokalaemia • Check BM/ dipstick urine (diabetes) • Bone scans (osteoporosis)

  33. Common questions • What is the difference between Cushing’s Disease and Cushing’s syndrome? • Commonest cause? • What are some of the other symptoms of Cushing’s syndrome? • Complications of Cushing’s Syndrome?

  34. Steroid use • Respiratory – asthma, COPD, pulmonary fibrosis • GI – IBD, AIH • Rheum – RA, SLE, polymyalgia rheumatica, GCA • Renal transplant

  35. Diagnosing Cushing’s • Screen • 24 hour urinary free cortisol • Confirm with 48 hour dexamethasone suppression (raised corisol? = cushing’s) • Locate cause -plasma ACTH – detectable = pituitary or ectopic - High dose dex test – Cushing’s disease vs ectopic (no suppression of cortisol)

  36. Treat the cause • Stop steroids • Remove tumour

  37. Acromegaly • Increased growth hormone from anterior pituitary tumour or (1%) carcinoid ectopic production • 5% cases are associated with MEN1

  38. Features • Enlargement of soft tissues • Insidious onset • Headache • Excess sweating • OSA • Arthralgia • Carpel tunnel syndrome • Proximal muscle weakness

  39. Acromegaly

  40. Acromegaly Complications • Impaired glucose tolerance • Vascular • Htn • LVH • Cardiomyopathy • Malignancy – colonoscopy every 3 years after 50yrs old

  41. General Inspection • Enlarged features!

  42. Hands • Big • Median nerve - thumb abduction • Thenar muscle wasting • Finger sensation • Feel palms – boggy and sweaty = active disease

  43. Arms • Carpal tunnel scar • Offer BP

  44. Face and visual fields • Enlarged supraorbital bridge • Prognathism • Enlarged ears, nose, lips • Wide teeth, enlarged tongue • Bitemporal hemianopia

  45. Neck • Thyroid enlargement

  46. Extras • Proximal myopathy • Dipstick urine/ check BM/ OGTT • CV examination and ECG • MRI brain • Series of photographs

  47. Questions • Complications • Yearly checkups – GH, ILGF1, OGTT, visual fields, CV exam, clinical photos and colonoscopy every 3-5 years after age of 50

  48. Treatment • Transphenoidal resection of the pituitary tumour • Measure GH after • ?need somostatin analogue = ocreotide

  49. Wee bit on Diabetes and Ethics stations • Communication skills • Empathy – explore patient reasons for presentation • Inform DVLA: - insulin; DM plus complication; severe hypo; bus/coach/lorry license • Diet only – no need to tell DVLA

  50. Any Questions?

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