History
Key features of the history in a patient with endocrine and metabolic disease are shown in Table 7.1.
Table 7.1 Key Features of the History in a Patient with Endocrine and Metabolic Disease
| Feature | Details | Rationale |
| Basic details | Age, sex, height, weight, reproductive status | Establish body mass index; consider growth and development disorders; subfertility |
| Symptoms | Weight changes; thirst and polyuria; heat intolerance; palpitations; tremor; pruritis; insomnia and irritability; lethargy; depression; diarrhoea or constipation; dry hair; hoarseness; swelling of the neck; dysphagia; periorbital swelling; change in nail beds; menstrual dysfunction; hirsutism; headaches; visual disturbance; muscle weakness; arthralgia; galactorrhoea; loss of libido; loss of secondary sexual characteristics; changes in facial appearance; xanthelasma; renal colic; tetany; skin changes – dry skin, acne, vitiligo, rashes, striae, foot ulcers; symptoms of specific lesions – acanthosis nigricans, pretibial myxoedema, necrobiosis lipoidica | Identify significant symptoms and patterns of change including relapsing patterns |
| Past medical history | Previous episodes of similar symptoms; other endocrine disorders; autoimmune disease; ischaemic heart disease; hypertension; bone fractures | Consider associated endocrine disorders or autoimmunity; effects of endocrine disease on cardiac dysfunction; hyperlipidaemia; secondary hypertension; endocrine manifestations of malignancy |
| Social and family history | Alcohol; smoking; diet; number of children and/or desire for pregnancy; family history of autoimmune endocrine disease or genetic cancers | Potential causes of endocrine disease; potential genetic syndromes or cancers |
| Medication | Review all medication including complementary therapies | Endocrine/metabolic side effects especially with corticosteroids, amiodarone, thiazides |
Examination
General observation: note
- height and weight – calculate body mass index (BMI – weight/height2)
- evidence of weight loss
- obesity and pattern of fat distribution
- loss of secondary sexual characteristics
- evidence of virilisation in women – male pattern hair distribution, altered muscle bulk and body habitus, deep voice and cliteromegaly
Where indicated, e.g. by delayed growth or lack of consonance of pubertal development, make a formal assessment of pubertal status.
Observe
Obvious features of classical endocrine and metabolic syndromes
- Graves’ disease
- hypothyroidism
- hyperlipidaemias
- polycystic ovary syndrome
- Cushing syndrome
- acromegaly
- altered mood
Speech and voice disorders
- hoarseness
- virilised – deep voice in women
- slow slurred speech in hypothyroidism
- pressure of speech in thyrotoxicosis
The emphasis of the examination of the endocrine system should be dictated by the particular organ system that appears to be involved.
Hands
Observe
- palmar erythema
- temperature and sweating
- fine tremor of outstretched hands
- thyroid acropachy
- onycholysis
- orange-yellow discolouration (carotenaemia)
- small muscle wasting
- extensor tendon xanthomas
- increased pigmentation of palmar creases
- soft tissue enlargement and arthropathy
Examine for
- Dupuytren’s contracture
- carpal tunnel syndrome: thenar wasting; appropriate sensory changes; perform Tinel’s test
- poor joint mobility: the ‘prayer sign’ will demonstrate impaired metacarpophalangeal (MCP) or interphalangeal (IP) joint extension
Arterial Pulse
- bradycardia
- sinus tachycardia
- atrial fibrillation
Blood Pressure
- lying and standing blood pressure: note postural hypotension
- Trousseau’s sign – maintaining the cuff at above systolic pressure for 3 min induces carpal spasm of the hand and wrist in the presence of hypocalcaemia
Skin
Observe
- hirsutism
- loss of body hair
- greasy skin and acne
- dry skin
- vitiligo
- bruising
- abdominal striae
- folliculitis
- eruptive xanthomatosis
Examine for
- lipodystrophy at insulin injection sites
- acanthosis nigricans
Face
Observe
- cranial nerve palsies
- xanthelasmata
- hypothyroid facies
dry, thickened skin
hoarse voice
periorbital puffiness
macroglossia, pallor and ‘lemon-yellow’ tinge when severe, causing anaemia and carotenaemia
- features of acromegaly
increased supraorbital ridges
protrusion of lower jaw (prognathism with malocclusion)
soft tissue overgrowth
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