Evaluation of the Patient with an Endocrine Disorder 2.pptx

Evaluation of the Patient with an Endocrine Disorder 2.pptx

1. Evaluation of the Patient with an Endocrine Disorder Ven. Prof. C. I. Okafor (FMCP)

2. OBJECTIVES Be able to list all the endocrine glands, their hormonal secretions, & functions. Be able to identify a patient with endocrine disorder from key symptoms & signs. Be able to list appropriate investigations for a patient with endocrine disorder(s). 3rd April 2024 2

3. 7/1/20XX 3 OUTLINE Identify the major endocrine glands. Identify the major pathologies of the glands. List the consequent symptoms & signs of the hormonal dysfunctions. Discuss the various investigative modalities of endocrine disorders

4. What are the major endocrine glands? 3rd April 2024 4 Endocrine system functions consists of: Hormonal secretion Transport of hormones via the blood as free & bound hormones (makes endocrine system involved in many disorders outside the ES) Receptor binding & Signal transduction Downstream effects (symptoms & signs)

5. What are the major endocrine glands? 3rd April 2024 5 Symptoms = Signs = ?

6. Grouping of Symptoms & signs 3rd April 2024 6 Generalized & non-specific S & S (constitutional symptoms) Local / pressure S & S Downstream effects (symptoms & signs)

7. Symptoms & signs of PITUITARY GLAND dysfunction Generalized & constitutional (non-specific) S & S Weight loss Body pain…… visual analog scale (VAS): 0 -4/5-44/45-74/75-100mm) Headache Sweating Fever……. warmth , high temperature Weakness 3rd April 2024 7

8. Symptoms & signs of PITUITARY GLAND dysfunction Generalized & constitutional (non-specific) S & S Malaise altered sensorium: Lethargy / Lassitude: A feeling of fatigue, tiredness and exhaustion both physically and mentally. Delirium: A temporary mental state characterized by confusion, anxiety, incoherent speech, and hallucinations. Coma: A state of prolonged unconsciousness in which the patient cannot easily be aroused from……. Glasgow Coma Scale [GCS] 3rd April 2024 8

9. 3rd April 2024 9 GCS = Blantyre = ?

10. Cranial space-occupying lesions Seizures: (due to presence of the lesion itself or its impact on nearby brain tissue). Cranial Nerve Palsies: Lesions can compress or damage cranial nerves Third Nerve Palsy: Compression of the oculomotor nerve can cause ipsilateral pupil dilation and complete third nerve paralysis. NB: DM neuropathy: pupillary sparing is noted. Other Cranial Nerves: double vision, facial weakness, or difficulty swallowing. 3rd April 2024 10

11. Cranial space-occupying lesions Visual Field Defects: optic pathways --- bitemporal VFD Language Dysfunction: Space-occupying lesions in language-related brain regions can cause language difficulties. For instance, lesions in the frontal or temporal lobes may lead to expressive or receptive language impairments. Features of Raised Intracranial Pressure (ICP): headaches, nausea, vomiting, altered consciousness, and papilledema (swelling of the optic disc - fundoscopy ). 3rd April 2024 11

12. Common Endocrine Symptoms Anthropometric measurements (& height)Weight loss /gain: Short /Tall stature / Obesity Mental: Hyperactive, dull, IQ, Anxious,…/ Insomnia/ drowsy/ somnolence Hair: Loss/ brittle ,dry …/Hirsutism Facial: moon face /exophthalmos /Vision disturbance/ anaemia Diffuse/nodular/neck swelling Voice change /difficult in swallowing Dry/sweaty hand/ skin pigmentation 3rd April 2024 12

13. Common Endocrine Symptoms Intolerance to heat or cold/Flushing /Fever.. Increased or decreased appetite/Polyphagia Polydipsia /Polyuria /Nocturia Pathological fractures/ Anasarca /Pedal oedema Delayed puberty/Delayed secondary sexual characteristics Erectile dysfunction/ loss of libido /Gynaecomastia Female : Delayed menarche/ abnormal MC/abortion history/congenital child birth 3rd April 2024 13

14. EVALUATION FOR SIGNS OF Endocrine DISORDER With the patient undressed, observe the body size and habitus . Body mass index [ Wt /[Ht 2 ]], waist circumference , Body proportion e.g : arm span :height ratio Arm span/height ratio: arm span is < height in early childhood, arm span = height by about 10 years in males and 12 years in females, arm span > height thereafter 18 yrs General nutrition: Thyroid & adrenal status, Cushing's disease/ Acromegaly/ dwarfism 3rd April 2024 14

15. EVALUATION FOR SIGNS OF Endocrine DISORDER Muscle and fat distribution: Central obesity Mental: Demeanor , Hyperactive, dull, level of IQ, Anxious,/Insomnia/ drowsy/ somnolence… Appearance:, moon face, facial hair, /Periorbital wrinkling /exophthalmos/Vision disturbance// bossing of forehead large lips ,nose 3rd April 2024 15 Central Obesity

16. Common Endocrine Symptoms Hair: Loss/ brittle ,dry …/Hirsutism Skin: vitiligo, hyperpigmentation Diffuse/nodular/neck swelling: goitre 3rd April 2024 16

17. PICTORALS 3rd April 2024 17 Gigantism Dwarfism

18. PICTORALS 3rd April 2024 18 Acromegaly Enlarged hands ,large nose, thick lips thickened skin

19. PICTORALS 3rd April 2024 19 Goitre Hypothyroidism Hair distribution,periorbital edema , thickened skin

20. PICTORALS 3rd April 2024 20 Preorbital wrinkling Exophthalmos Ophthalmoplegia Visual field defect Redness of eyes

21. PICTORALS 3rd April 2024 21 Pigmentation of hand crease Large sweaty fleshy hands Tremor Palmar erythema Pulse and blood pressure Diabetic cheiropathy with classic periarticular tightening [suggests vascular disease high risk for heart disease]. Proximal muscle weakness [hyperthyroidism & Cushing's diseases]

22. PICTORALS 3rd April 2024 22 Hypocalcaemia: Carpopedal Spasm & Chovsteks signs

23. 3rd April 2024 23 Cushing syndrome Moon face & skin striae, Gynaecomastia PICTORALS

24. PICTORALS Orchidometer 24 Chest and abdomen : Breasts : Size /shape /Discharge [in both male and female] • Gynaecomastia [Male] • Galactorrhoea •Striae over abdominal skin / hyper or hypopigmentation / Genitalia •Distribution of pubic hair •Secondary sex characteristics •Male: Virilization • b. testicular volume Male Female PUBIC LINE

25. PICTORALS 25 Chest and abdomen : Breasts : Size /shape /Discharge [in both male and female] • Gynaecomastia [Male] • Galactorrhoea •Striae over abdominal skin / hyper or hypopigmentation / Acute Pancreatitis: Garay Turner [subcutaneous Tissue] Cullen - umbliCUs

26. PICTORALS 3rd April 2024 26 Lower limbs: Pretibial myxoedema and proximal myopathy

27. PICTORALS 3rd April 2024 27 Lower limbs: Shiny thin skin with absence of hair on the lower extremities and absent pulses in the feet suggest [macrovascular or microvascular compications of DM]. Sensory examination: DM Neuropathy [cotton wool sensation / pin prick / joint position sense / vibration sense: 128Hz tuning fork / biothesiometer

28. PICTORALS 3rd April 2024 28 Lower limbs: Shiny thin skin with absence of hair on the lower extremities and absent pulses in the feet suggest [macrovascular or microvascular disease of DM]. Sensory examination: DM Neuropathy [cotton wool sensation / pin prick / joint position sense / vibration sense: 128Hz tuning fork / biothesiometer

29. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 29 Imaging studies: X-rays, Ultrasonography, CT scans, MRI, DEXA scans. Tissue studies: biopsies for histological evaluation: thyroid nodules, tumours Hormonal assays: blood & urine Genetic studies / immunologic studies Chemistries: blood & urine Haematological studies

30. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 30 Imaging studies: X-rays, Ultrasonography, CT scans, MRI, DEXA scans. X-rays: erosion of the clinoid processes [pituitary tumours], thoracic inlet [retrosternal goitre],

31. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 31 Imaging studies: X-rays, Ultrasonography, CT scans, MRI, DEXA scans. X-rays: Abdominal x-ray: pancreatic calcifications [ Fibrocalculous pancreatic diabetes, Hyperparathyroidism: [Approx: 10% of cases of hyperparathyroidism] hyperparathyroidism is associated with nephrocalcinosis (calcification in the kidneys) or urolithiasis (kidney stones)

32. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 32 Imaging studies: X-rays, Ultrasonography, CT scans, MRI, DEXA scans. X-rays: osteoporosis / lytic bone lesions Osteomyelitis: DFU, charcoat’s arthropathy

33. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 33 Imaging studies: X-rays, Ultrasonography, CT scans, MRI, DEXA scans. Ultrasonography Goitre: diffuse / nodules / cysts Abdomen: fatty liver [DM[, Adrenal Masses, nephromegaly [early stages of DM Nephropathy]

34. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 34 Imaging studies: X-rays, Ultrasonography, CT scans, MRI, DEXA scans. CT scans Brain masses, throid , abdomen: adrenals – phaechromocytoma , Adenomas, chest: ectopic ACTH secreting tumors e.t.c MRI: Pituitary masses / intracranial masses Dual Energy X-ray Absorptiometry: BMD for osteoporosis.

35. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 35 Tissue studies: biopsies for histological evaluation: thyroid nodules, other tumours Histopathological studies

36. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 36 Hormonal assays: blood & urine GH / IGF-1: growth disorders TFT PRL - prolactin PTH Gonadal steroids: FSH, LH, Testesterone , DHEAS, C-peptide , FPI

37. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 37 Hormonal assays: blood & urine Cortisol,: UFC, late night salivary cortisol, Low dose Dexamethasone Suppression Testv [DST], High dose DST, ACTH – Cushing’s syndrome Plasma / urinary Metanephrines / VMA [ phaechromocytoma ] Genetic studies / immunologic studies : barr bodies, chromosomal studies: Klinifelter’s syndrome-47XXY, Turner’s syndrome – 45XO, Trisomy 21 [Down’s syndrome] e.t.c

38. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 38 Chemistries: blood & urine SEUC: Hypo/ hypernatraemia , hypo/hyperkalaemia, hipocalcaemia FBG / RBG , HbA1c, ketones, lipid profile. DKA: hyperglycaemia + Ketosis + acidosis HHS: high plasma osmolality: Na+ k+, Glucose [mmol/l]

39. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 39 Haematological studies FBC: anaemia: Hypothyroidism {normocytic, macrocytic, or microcytic; coexisting deficiencies of iron, B12, and folate]. Hyperthyroidism [increased red cell mass, with increased plasma volume. Addison’s disease: reduced cell mass + reduced plasma vol may mask it

40. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 40 Haematological studies FBC: anaemia: Gonadal hormones Decrease in androgen production due to orchiectomy or medical androgen blockade. Reduced Stimulation of erythropoietin secretion and a direct effect on the marrow erythroid progenitors.

41. LABORATORY EVALUATION OF ENDOCRINE DISORDERS 3rd April 2024 41 Haematological studies FBC: anaemia: Estrogens in large doses cause moderately severe anaemia [mechanism unknown] Polycythemia has been reported in cushing syndrome, primary aldosteronism, bartter’s syndrome, and congenital adrenal hyperplasia secondary to 21-hydroxylase deficiency.

42. Summary Endocrine disorders can be subtle to pick Requires high index of suspicion. Laboratory Investigations are key but can be challenging in resource-poor countries 3rd April 2024 42

43. 3rd April 2024 43 Thank you

44. Thank you Presenter name Email address Website 3rd April 2024 44