ENDOCRINE PHYSICAL EXAMINATION

General
Appearance
● Characteristic
syndrome
appearance.
● See
Common
Syndrome
Exams
Reference.
● Stature.
● Weight.
● Ask
pt.
if
any
part
tender
before
palpating.

Hands
● Oversized
hands
(acromegaly). → ekskresi hor mon dari pituitary lbedakan dgn gigantism e)

Hypothyroid :
ding in

tremor
cara perils a
I. tang an mengadah
2. letakkan kertas

● Heat
(hyperthyroid). → tanganmudah bertie ring at

● Tremor
(hyperthyroid).
● Palmar
erythema
(hyperthyroid). 1k has sins is gg )
↳
bias anya pd tenor

● Pigmentation
of
palmar
crease
(Addison's,
but
normal
in
asians,
blacks).
● 3rd,
5th
metacarpals
shortened
(pseudohypoparathryoid).
-
→ mirip primary hyper parathyroid
→ Iue to
● Pulse:
rate
(hyper-,
hypothyroid),
rhythm,
character.
< 100 → hyper [ tacky )
4 hyperthyroid :
Kuatangkat
aritmi :
hypo - i - i lemah

Arms to cortisol increase

→ due
● Blood
pressure
for
hypertension
(Cushing'),
hypotension
(Addison's).
→ kekurangan Forti so I adrenal Iv
● Trousseau's
sign
(hypercalcemia): chovstelk sign → hypocalcemia
○ Occlude
brachial
artery
for
3
min
using
BP
cuff.
-

○ See
if
carpal
spasm
is
induced.
● Muscle
weakness
(hypothyroid,
Cushing's).
Axillae
→ hitam
● Acanthosis
nigricans
(acromegaly).
● Axillary
hair
loss
(hypopituitary).
● Skin
tags
(acromegaly).

Face
● Syndrome
facies. →

● Acne,
oily
skin
(Cushing's). → cortisol induce oil secretion

● Hirsutism
(panhypopituitary).
● Chin
enlargement
(acromegaly).

Eyes Spt Orang melotot

→
.

● Exophthalmos
(hyperthryoid). =) Khas grave disease

● Eye
fundus: → bs make funduscopy

○ DM
○ acromegaly

Mouth lateral
11
● Buccal
pigmentation
(Addison's).
lbagian pipidalam )
● Tongue
enlargement
(acromegaly).
↳ hypothyroid

Neck tumpukan
→ Kaya ada
● Inspect
buffalo
hump
(Cushing's).
● Palpate
supraclavicular
fat
pads
(Cushing's).
● Inspect
webbed
neck
(Turner's).
↳ bs pd down syndrome yg .

Thyroid
● Inspect
for
goiter.
● Dr.
palpates
pt's
thyroid
from
behind.

Chest
● Pigmented
nipple
(Addison's).
 ● Loss,
gain
of
chest
hair.
● Male
gynecomastia
(Cushing's).
● Reduced
female
breast
size
(panhypopituitary).
↳ masala hdgn LH ) FSH

Abdomen
● Pt.
lies
down,
one
pillow
under
head.
● Purple
striae
(Cushing's).
→
→ Spt ibn barn hamil

● Disproportionate
abdominal
fat
(Cushing's).

Genitalia
● Atrophy. → pituitary ( hypno)

● Virilisation.

Legs
● Peripheral
neuropathy
(DM).
● Toenails
and
foot
showing
same
symptoms
as
Fingernails
and
Hands.
 Endocrine System Examination (Reference II)
Reference II

THYROID
GLAND
EXAMINATION

GENERAL
APPEARANCE:
● Weight
loss. ( hyper : kurus, hypo gendntj
:

● Anxiety.
● Frightened
facies
(thyroid
stare).

HANDS:
● Onycholysis
(Plummer’s
nails)
particularly
on
the
ring
finger.
Rarely
seen
in
Graves’
disease.
● Thyroid
acropachy
(clubbing).
● Fine
tremors
(sympathetic
over
activity).
● Moisture
&
warmth
(sympathetic
over
activity).
● Palmer
erythema.

VITAL
SIGNS:
● RADIAL
PULSE
○ Sinus
tachycardia.
○ Collapsing
character
(high
cardiac
output).
○ Irregularly
irregular:
atrial
fibrillation.
○ Regular
with
periods
of
irregularity:
extrasystole. 1 due to HF )

● BLOOD
PRESSURE.
● TEMPERATURE.
● RESPIRATORY
RATE.

ARMS:
● Proximal
myopathy
(ask
the
patient
to
raise
the
arms
above
the
head).
● Exaggerated
reflexes
(esp.
in
relaxation
phase).
EYES:
● EXOPHTHALMOS
(PROPTOSIS):
Protrusion
of
the
eyeball
out
of
the
orbit
(occurs
bilaterally
only
in
Graves’
disease).
○ Sclera
visible
below
or
all
around
the
iris.
○ Patient
can
look
up
without
wrinkling
the
forehead.
○ Difficulty
in
converging
○ Patient
cannot
close
the
eyelids.
○ Eyeball
is
visible
anterior
to
superior
orbital
margin.
● CHEMOSIS:
○ Thickening,
crinkling,
oedema
&
opacity
of
conjunctiva
particularly
over
the
insertion
of
the
lateral
rectus
muscle.
te Kanan osmotik
● CONJUNCTIVITIS: peningkatun
● CORNEAL
ULCERATION:
due
to
inability
to
close
the
eyelids. → ophtalmopathy
● OPTIC
ATROPHY:
due
to
optic
nerve
stretching.
● OPHTHALMOPLEGIA:
Patient
cannot
look
upwards
&
outwards
● LID
LAG:
The
upper
eyelid
cannot
keep
pace
with
the
eyeballs
as
it
follows
a
finger
moving
from
above
-

downwards.
● LID
RETRACTION:
Sclera
visible
above
the
superior
limbus
of
the
iris.
● LEUKOTRICHIA:
White
discoloration
of
the
eyelashes.

NECK:
● INSPECTION:
=

Look
at
the
front
&
sides
of
the
neck
&
decide
if
there
is
localized
or
general
swelling
of
the
gland.
● Swelling
(enhanced
by
asking
the
patient
to
swallow
sips
of
water):
○ Shape
(nodular
or
diffuse).
-
-
0
○ Movement
during
swallowing
(only
a
goiter
or
thyroglossal
cyst
will
rise
during
swallowing).
○ Inferior
border.
● Scars
(thyroidectomy
scar).
● Prominent
veins
(over
the
upper
part
of
the
chest,
often
accompanied
by
↑
JVP.
Suggest
retrosternal
extension
of
the
goiter
­thoracic
inlet
syndrome-).
 ● Erythema
of
skin
(in
case
of
suppurative
thyroiditis).

There
is
diffuse
thyroid
swelling
that
moves
freely
with
swallowing
&
its
inferior
border
is
visible.
No
scars,
prominent
veins
or
erythema
of
skin.

● PALPATION:
begun
from
behind.
○ Size:
look
for
the
lower
border,
if
absent,
may
be
retrosternal
extension).
○ Site: * raba
is mus Tg

○ Shape:
kantnng ada air
Kissy
→
* consistency :

○ Diffuse
enlargement.
○ Solitary
nodule: * thyroiditis : add nyeri

■ Location.
■ Size.
■ Consistency:
○ Soft:
simple
goiter.
○ Rubbery
hard:
Hashimoto’s
thyroiditis. (
hypothyroid )
○ Stony
hard
node:
carcinoma,
calcification
in
a
cyst,
fibrosis,
or
Riedel’s
thyroiditis.
○ Tenderness.
○ Mobility.
○ Multinodular.
○ Surface:
○ Temperature:
thyroiditis.
○ Tenderness:
Thyroiditis
(subacute
or
rarely
suppurative),
bleeding
into
cyst
or
carcinoma.
○ Texture:
○ Thrill:
in
thyrotoxicosis.
○ Consistency:
firm
or
stony
hard.
○ Relation
to
surrounding
structures:
tethering
or
fixation
to
overlying
skin
or
underlying
tissues
in
thyroid
carcinoma.
○ State
of
regional
L.N:
enlarged
in
carcinoma.
○ State
of
local
tissues
(due
to
malignancy
infiltration
by
thyroid
carcinoma)
○ Arteries:
bruits
over
the
carotids.

*
hyperthyroid : ada kemungkinandeviasi trakea
 ○ Veins:
venous
hum.

NOW,
move
to
the
front.
Note
the
position
of
the
trachea,
which
may
displaced
by
a
retrosternal
gland.

● PERCUSSION:

Percuss
the
upper
part
of
the
manubrium
from
one
side
to
the
other.
If
percussion
notes
changed,
=

this
may
indicate
retrosternal
extension.
normal : dull Kalo terlakt dull → kemungkinan metastasis dart
, thyroid CA

● AUSCULTATION:
Listen
for
a
bruit
over
each
lobe
which
occur
in:
○ Hyperthyroidism.
○ Using
of
antithyroid
drugs.

CHEST:
Thoracic
inlet
obstruction
“Pemberton’s
sign”:
by
asking
the
patient
to
lift
both
arms
as
high
as
possible.
Wait
for
few
minutes:
● Congestion
of
the
face
(plethora).
● Cyanosis.
● Respiratory
distress
&
inspiratory
stridor.
● Neck
venous
distention
(venous
congestion).

This
occurs
with
retrosternal
goiter
or
any
retrosternal
mass.
● Gynaecomastia
(occasionally
with
thyrotoxicosis,
or
with
panhypopituitarism).
● Systolic
flow
murmurs
(due
to
↑
cardiac
output).
● Signs
of
CHF
esp.
in
elderly
(precipitated
by
thyrotoxicosis).
THE
LEGS:
● Look
for
pretibial
myxoedema
(bilateral
firm
elevated
dermal
nodules
&
plaques
which
can
be
pink,
brown,
or
skin
colored).
○ Due
to
accumulation
of
mucopolysaccharide.
○ This
occurs
only
in
Graves’
disease
&
not
in
hypothyroidism.
● Test
for
proximal
myopathy
&
reflexes
in
the
legs.
 DIABETES MELLITUS PHYSICAL EXAMINATION

● If FBS ≥ 7.8 mmol/L. or the 2 hour postprandial BSL of 11.1 mmol/L or more in more than one
occasion.
● Primary:
either
type
I
or
type
II.
● Secondary: hormone ­induced state (acromegally, Cushing’s syndrome, phaeochromocytoma, and
glucagonoma).
● Drugs:
steroid,
thiazide,
phenytoin,
the
contraceptive
pills,
and
diazoxide).
● Pancreatic
disease
(carcinoma,
chronic
pancreatitis,
haemochromatosis).

GENERAL
SYMPTOMS:
Polyuria,
polydiapsia,
polyphagia,
blurred
vision,
weakness,
tiredness,
lethargy,
infections,
groin
itch,
weight
loss,
disturbance
of
conscious
state,
rash
(pruritis
vulvae,
balanitis).

GENERAL
APPEARANCE:
● Evidence
of
dehydration
(osmotic
diuresis).
● Obesity
(type
II
DM).
● Recent
weight
loss
(evidence
of
uncontrolled
glycosuria).
● Abnormal
endocrine
facies
(acromegally,
Cushing’s
syndrome).
● Pigmentation
(haemochromatosis
“bronze
diabetes”).
● Kussmal’s
breathing
“Air
Hanger”
(diabetic
ketoacidosis)
↳ cepat } dalam

LOWER
LIMBS:
INSPECTION:
● SKIN:
○ Hairless
&
atrophied
(small
vessels
vascular
diseases
&
resultant
ischemia).
○ Leg
ulcers
­on
the
toes
or
any
pressure
areas-
(ischemia,
peripheral
neuropathy).
○ Skin
infections
“boils,
cellulitis
&
fungal
infections”
(↑
glucose,
ischemia).
○ Pigmented
scar
(late
diabetic
dermopathy).
○ Necrobiosis
Lipoidica
Diabeticorum:
over
the
skin
&
it
is
a
central
yellow
scarred
area,
which
surrounded
by
a
red
margin
when
the
condition
is
active.
 ○ Insulin
injection
sites
(usually
in
the
thigh):
may
associated
with
localized
fat
atrophy
&/or
hypertrophy.

● MUSCLE
WASTING:
○ Note
any
Quadriceps
muscle
wasting
due
to
femoral
nerve
mononeuropathy.
This
is
called
“Diabetic
Amyotrophy”.

● KNEE:
Rare
“
Charcot’s
joint
“:
grossly
deformed
&
disorganized
joint
due
to
loss
of
proprioception
or
pain
or
both.
cek tendon pd patella

PALPATION:
● Injection
sites
for
fat
atrophy
or
hypertrophy.
● Feel
all
peripheral
pulses,
temperature,
and
tests
the
capillary
return
­
if
↓-(peripheral
vascular
disease).
[ dorsalis pedis , inguinal , popliteal ,
achilles ]
NEUROLOGICAL
EXAMINATION:
● Check
for
sensation,
muscle
power
&
tap
reflexes.
extra :
aek cellulitis

UPPER
LIMBS:
● Nail:
for
signs
of
candidal
infections.
● Inspect
&
feel
for
the
injection
sites
over
the
forearm.
● Take
blood
pressure
lying
&
standing
“autonomic
neuropathy”
which
may
lead
postural
hypotension.

FACE
EXAMINATION:
● EYES
○ Visual
acuity,
which
may
be:
○ Permanent:
due
to
retinal
diseases.
○ Temporarily:
due
to
disturbed
the
shape
of
the
lens
associated
with
hyperglycemia
&
water
retention.
○ Argyll
Ropertson
pupils:
which
is
rare
in
DM.
○ Rubeosis
iridis,
cataract:
due
to
deposition
of
sorbitol
in
the
lens.
 ○ Diabetic
retinopathy:
■ Non-proliferative:
dot
&
blot
hemorrhage,
microaneurysms,
heard
&
soft
exudates.
■ Proliferative:
new
vessels
formation,
which
may
lead
to
vitreal
hemorrhage,
scar
formation
&
eventually
retinal
detachment.
○ Check
for
Laser
scars
(small
brown
or
yellow
spots).
○ Assesses
the
3rd,
4th
&
6th
cranial
nerves
esp.
3rd
nerve
palsy
from
ischemia
which
tends
to
spares
the
pupils. 11-11:&:)
○ Other
cranial
nerve
palsies
(due
to
CVA
by
large
atheroma).
○ Rhinocerebral
mucormycosis
(rare
in
uncontrolled
patient
causing
periorbital
&
perinasal
swelling
&
cranial
nerve
palsies).
● EARS
→ klditarikkvpingnya nyeri
○ Evidence
of
Malignant
Otitis
Externa
caused
by
“Pseudomonas
Aeruginosa”. due to immunocompromised

○ Facial
nerve
palsy
(in
50
%).
● MOUTH * penurunan reflex
○ Evidence
of
candidal
infections. fisio logit
-
raba tendon , lcemudian

NECK
&
SHOULDERS
● Examine
carotid
artery
for
evidence
of
vascular
diseases.
lihatadakontmks.CN
dilator
:
) tttt
,

1- 4

● Check
for
the
thickening
of
the
upper
back
&
shoulders
(evidence
of
Scleroderma).
● Acanthosis
nigricans
(in
insulin
resistant
cases).
0

CHEST:
● For
signs
of
infections.

ABDOMEN:
● Palpate
hepatomegaly
due
to
fatty
infiltration
or
due
to
haemochromatosis.
ulu hati muntah
• Gastro path y :
peace-c di tanya moral .

06h
→ men
g- ukur
BP pd brachial Kiri g. Kanan, icemudian di banding Kan
Index ) 4
manifest asi dari PAD ankle ( dorsalis
ABI ( Ankle Brachial
Important :

pedis)
Cari apaknh add komplikasi miking makrovaskular µ
fan tanda ? infeltsioportunil.PK N 0,9 I
-
: -

lperbandingan ,

bila Kuning,
Icemnngkinan PAD)