Endocrine Diabetes Mellitus General inspections Signs of dehydration. Obesity Signs of recent weight loss -> skin folds, clothing too loose Kussmaul’s breathing Lower Limbs Inspection: Look at the skin: Small vascular disease -> ischemia -> hairless and atrophied Leg ulcers -> due to a combination of ischemia and peripheral neuropathy. Loss of proprioception and/or pain -> ankles for signs of Charcot’s joints -> grossly deformed disorganised joints High glucose levels and ischemia -> signs of infections -> boil, cellulitis and fungal infections. Pigmented scars (late diabetic dermopathy) -> small, rounded plaques with raised boarders in linear fashion over the shins. Necrobiosis -> reasonably specific skin manifestations but it is rare. Look at the thighs for signs of insulin injections -> these may be associated with fat atrophy and hypertrophy. Look at the quadriceps for signs of muscle atrophy. Palpation: Palpate any injection sites for fat atrophy or hypertrophy. Feel all peripheral pulses. Feel temperature of the limbs Cold peripheries, absent peripheral pulses and reduced capillary refill -> signs of vascular disease. Neurological examination: Assess of peripheral neuropathy -> including dorsal column loss -> diabetic pseudotabes (due to extensive ANS involvement): Postural hypotension Vasomotor instability Tachycardia Anhidrosis Dependent edema Trophic skin changes Test for proximal muscle powder -> diabetic amyotrophy Monofilament testing for peripheral neuropathy in the feet: Gently press the monofilament against different areas in the foot. If the patient cannot feel it -> there is a loos of protective sensation -> increase risk of injury. Upper limb examination Nails -> signs of Candida infection Test for blood pressure with patient lying down and then standing -> postural hypotension. Face Visual acuity: May be permanently impaired due to retinal disease May be temporarily impaired due to changes in the shape of lens (associated with hyperglycaemia and water retention). Argyll Robertson pupils (rare complication of diabetes). Bilateral small pupils that fail to constrict in response to bright light but exhibit constriction during nail vision tasks. Cataracts -> related to sorbitol deposition in the lens (which glucose is present in high concentration in the tissues and is converted to sorbitol by aldose reductase). Non-proliferative changes: Retina examination using fundoscopy: Non-proliferative changes -> directly related to ischemia of blood vessels: Dot haemorrhages -> in inner retinal layers. Blot haemorrhages -> larger and occur more superficially in the nerve fibre layer. Microaneurysms -> due to vessel wall damage. Two types of exudates: Hard exudates -> straight edges. Soft exudates -> cottonwool spots and have fluffy appearance. Proliferative changes: Blood vessel changes in response to ischemia of the retina. New vessel formation -> vitreal haemorrhage -> scar formation -> retinal de-attachment -> appears as opalescent sheet that balloons forward into the vitreous. The underlying choroid is visible through the de-attached retina as bright red-coloured sheet. Look for laser scars -> small brown or yellow spots -> secondary to photocoagulation of new vessels by new therapy. Assess third, fourth and sixth cranial nerves. Especially CN III nerve palsy from ischemia -> spared the pupil Because infarction of the CN III affects the inner pupillary fibres more than the outer fibres -> differs from compressive lesions -> have the opposite effect. Rhino cerebral mucormycosis (rare): Develop in poorly controlled diabetes. Periorbital a d perinasal swelling. Other cranial nerve palsy Ears Look for evidence of infection Malignant otitis externa: Usually due to pseudomonas aeruginosa -> mound of granulation tissue in the external canal and facial nerve palsy -> in 50% of cases. Mouth Look for evidence of Candida infection. Look for evidence of periodontal disease. Neck and shoulders Carotid arteries -> evidence of vascular disease Rarely thickening of the skin of the upper back and shoulders -> scleroderma diabeticorum Diffuse cutaneous infiltration -> different distribution than typical scleroderma Acanthosis with insulin resistance. Abdomen Palpate for hepatomegaly: Fatty infiltration or haemochromatosis Signs of cirrhosis: Non-alcoholic steatohepatitis Urinalysis Glucose Protein Hyperparathyroidism General inspection Mental state If severe -> cardiac arrythmias Assess hydration: Hypercalcemia -> polyuria -> dehydration. Eyes Band keratopathy Body and lower limbs Proximal muscle weakness Fractures Assess blood pressure for hypertension Urinalysis Assess for renal stones Other features to look for in history and physical exam Generalised weakness Arrythmias LVH Nephrolithiasis Abdominal pain/flank pain Bone, muscle and join pain Pseudogout Lack of appetite -> weight loss Nausea Constipation Gastric or duodenal ulcers Acute pancreatitis Depression Fatigue Sleep disorders Anxiety Hypoparathyroidism Presents with hypocalcaemia with neuromuscular consequences (tetany) Look for Trousseau’s sign: Blood pressure cuff place on arm with the pressure raised above the patients SBP. Typical contraction of the hand occurs within 2 minutes due to hypocalcaemia causing neuromuscular irritability. Thumb becomes strongly adducted and the fingers are extended expect at the MCP joint. Look for Chovostek’s sign: Tap generally over the CN VII under the ear. Hypocalcaemia -> CN VII -> hyper-excitable. Hyper-reflexia due to neuromuscular irritability. Look at nails for fragility. Look at nails for monilial infection (fungal infections?) Examine the teeth for deformities. Examine the eyes for cataracts. Grave’s Disease Tachycardia Tremors Weight loss Hair loss Anxiety Diffuse goitre Smooth and uniformly enlarged Bruit Pemberton’s sign Exophthalmos Lid lag Thyroid dermopathy: Bilateral pretibial non-pitting edema and skin thickening -> pretibial myxedma. Plaques and nodules may be seen. Thyroid acropachy. Diarrhea Thyroid carcinoma Thyroid nodule Firm to hard consistency. Typically, painless Dysphasia Dyspnoea Horner’s syndrome Venous obstruction IJV Thrombosis SVC syndrome Tachycardia Weight loss Tachycardia Anxiety Tremors Restlessness Toxic Multinodular Goitre Painless goitre with multiple nodules Heat intolerance Excessive sweating Tremors Palpitations Onycholysis Tachycardia Subacute thyroiditis Fever Malaise Painful, diffuse and firm goitre Jaw pain Features of hyperthyroidism followed by features of hypothyroidism. Severe neck pain Hashimoto’s Non-tender goitre Moderate symmetrical enlargement Transient hyperthyroidism Cold intolerance Weight gain Depression Constipation Fatigue Bradycardia Riedel’s Thyroiditis Hard, fixed and painless goitre Dysphagia Hoarseness Dyspnoea Involvement of other surrounding structures Parathyroid glands Trachea Oesophagus Skeletal muscles, nerves and blood vessels. Cushing’s Syndrome General inspection Central obesity Skin bruising Skin pigmentation Muscles atrophy Hirsutism Plethora Acne Telangiectasia Moon shape Eyes Visual defects Fundoscopy Look for papilledema Optic atrophy Hypertensive and diabetic changes. Neck Supraclavicular fat pads Chest Gynecomastia Arms and legs Acanthosis nigricans Test for proximal myopathy of the upper and lower limbs Look for edema Look for poor wound healing Back Examine for buffalo hump and feel for it. Look for kyphoscoliosis and tap the spine for tenderness due to osteoporotic vertebral crush fractures. Patient laying flat Examine the abdomen for adrenalectomy scars Pigmentation Striae Adrenal masses Examine the liver for tumor deposits Others Urine analysis for glucose BSL Take blood pressure Acromegaly Hands and arms Enlargement of the fingers Increased sweating Increased warmth Phalen’s test at the wrists for carpal tunnel syndrome Feel the ulnar nerve at the elbow for thickening Test for proximal myopathy Look at axilla for skin tags -> molluscum fibrosum Greasy skin Acanthosis nigricans OA like features in Hands Shoulders Hips Knees Eyes Visual fields Fundoscopy Optic atrophy Papilledema Angioid streaks on retinal veins Mouth Large tongue that may be too big to fit into the mouth Enlargement of lower jaw -> prognathism Teeth splaying Hirsutism in women Deep, husky and resonant voice. Neck Thyroid gland Diffuse enlargement Multi-nodular goitre Cardiovascular system Signs of congestive heart failure Abdomen and organomegaly of: Liver Spleen Kidney Genitals Look for signs of hypogonadism Secondary to enlarging pituitary adenoma Lower limbs Look for osteoarthritis and gout Look for foot drop Due to entrapment of the peritoneal nerve. Feel for heel pad thickening Others Look for evidence of hypothyroidism and adrenocortical insufficiency Urine analysis -> glucose secondary to glucose intolerance Blood pressure -> hypertension Decide if acromegaly is active: Number of skin tags Sweating Presence of glucosuria Increasing visual defects or development of nerve palsies in nerves III, IV, VI and V. Enlarging goitre Hypertension Headache Increasing ring size Increasing shoe sizes Ability to denatures to fit in i.e. not too small.