Lekcja 3: Badanie i Ocena Stanu Pacjenta | Patient Examination and Assessment

Examination of the Endocrine System

The physical examination of the endocrine system aims to identify signs of hormonal imbalance or glandular dysfunction. A systematic assessment typically involves evaluating specific glands and hormone-related symptoms.

General Inspection:

  • Weight and Body Composition: Sudden weight gain or loss can indicate thyroid, adrenal, or pancreatic dysfunction.
  • Skin Changes: Dry skin or thinning hair may suggest hypothyroidism, while hyperpigmentation could indicate adrenal insufficiency (e.g., Addison’s disease).
  • Energy Levels: Fatigue, weakness, and lethargy are common in endocrine disorders such as hypothyroidism and adrenal insufficiency.

Examination of Specific Glands:

1. Thyroid Gland:

  • Inspection: Look for visible enlargement of the thyroid gland (goiter). Observe any swelling in the neck that moves when the patient swallows.
  • Palpation: The thyroid gland is palpated from behind the patient, with fingers placed on the thyroid cartilage to assess size, shape, and consistency. Nodules or asymmetry may indicate conditions such as thyroid nodules, cancer, or goiter.
  • Auscultation: In hyperthyroidism, a thyroid bruit (sound of increased blood flow) can sometimes be heard over an enlarged gland.

2. Adrenal Glands:

  • Blood Pressure Measurement: Hypertension may suggest excess cortisol or aldosterone production (Cushing’s syndrome or primary hyperaldosteronism). Conversely, low blood pressure can indicate adrenal insufficiency.
  • Skin Pigmentation: Hyperpigmentation on the palms, elbows, and knees may suggest chronic adrenal insufficiency (Addison’s disease).
  • Physical Strength and Reflexes: Muscle weakness and decreased reflexes may be observed in disorders like Cushing’s syndrome.

3. Pituitary Gland:

  • Visual Field Testing: Tumors of the pituitary gland, such as pituitary adenomas, can impinge on the optic chiasm, causing bitemporal hemianopia (loss of peripheral vision).
  • Height and Growth Assessment: The presence of gigantism (excess growth hormone in children) or acromegaly (excess growth hormone in adults) may be observed through disproportionate growth of the hands, feet, and facial features.

4. Gonads (Ovaries and Testes):

  • Secondary Sexual Characteristics: Delayed puberty, irregular menstrual cycles, and gynecomastia in males may indicate hormonal dysfunction related to the gonads.
  • Testicular Examination: Evaluate for testicular atrophy, which may indicate endocrine disorders such as hypogonadism or Klinefelter syndrome.

5. Pancreas (Endocrine Function):

  • Skin and Nail Changes: Diabetic patients may exhibit acanthosis nigricans (darkened skin) and brittle nails, which could indicate underlying insulin resistance or high blood sugar levels.
  • Peripheral Neuropathy: A test for decreased sensation in the extremities can detect complications of diabetes, which is associated with pancreatic endocrine dysfunction.

Diagnostic Tests and Procedures for Endocrine Disorders

Laboratory testing and imaging are essential for diagnosing and monitoring endocrine diseases. These tests assess hormone levels, gland function, and potential structural abnormalities.

1. Blood Tests for Hormonal Levels: Blood tests provide a direct assessment of hormone levels to diagnose various endocrine disorders.

  • Thyroid Function Tests:
    • TSH (Thyroid-Stimulating Hormone): Elevated TSH suggests hypothyroidism, while suppressed TSH levels indicate hyperthyroidism.
    • Free T4 and T3: These measure the levels of active thyroid hormones in the bloodstream and help confirm thyroid dysfunction.
  • Cortisol and ACTH (Adrenocorticotropic Hormone):
    • Morning Cortisol Levels: Low levels may indicate adrenal insufficiency, while elevated levels could be a sign of Cushing’s syndrome.
    • ACTH Levels: Used to differentiate between primary (adrenal) and secondary (pituitary) adrenal disorders.
  • Growth Hormone (GH) and IGF-1 (Insulin-Like Growth Factor):
    • High GH levels, along with elevated IGF-1, indicate acromegaly or gigantism, while low levels may suggest GH deficiency.
  • Sex Hormones (Estrogen, Testosterone, FSH, LH):
    • Abnormalities in these hormone levels may point to gonadal dysfunction or pituitary disorders affecting reproductive health.
  • Glucose and Insulin Tests:
    • Fasting Blood Glucose and HbA1c are crucial for diagnosing and managing diabetes, a disorder of pancreatic endocrine function.
    • Insulin Levels: High insulin levels may suggest insulin resistance, while low levels can indicate pancreatic insufficiency.

2. Stimulation and Suppression Tests:

These dynamic tests assess how well glands respond to regulatory signals, helping to identify functional abnormalities.

  • ACTH Stimulation Test: Used to diagnose adrenal insufficiency. The patient is given synthetic ACTH, and cortisol levels are measured before and after administration.
  • Dexamethasone Suppression Test: Helps diagnose Cushing’s syndrome by measuring the suppression of cortisol after administering dexamethasone (a synthetic glucocorticoid).
  • Oral Glucose Tolerance Test (OGTT): Used to diagnose diabetes and insulin resistance. After a glucose load, blood sugar levels are measured over time to observe how the body processes glucose.

3. Imaging Studies:

Imaging is often needed to assess the size, shape, and function of endocrine glands, especially in cases of tumors or structural abnormalities.

  • Ultrasound: Commonly used for evaluating the thyroid gland and detecting nodules, cysts, or goiter.
  • CT (Computed Tomography) and MRI (Magnetic Resonance Imaging):
    • Adrenal Glands: Used to detect tumors, such as adrenal adenomas or pheochromocytomas, which can cause hormone imbalances.
    • Pituitary Gland: MRI is the gold standard for detecting pituitary tumors (e.g., adenomas) that may cause hormonal imbalances.
  • Bone Densitometry (DEXA Scan): Used to assess bone density in patients with long-term endocrine disorders like hyperparathyroidism or Cushing’s syndrome, which can lead to osteoporosis.

4. Biopsy and Fine Needle Aspiration (FNA):

  • Thyroid Biopsy/FNA: If a thyroid nodule is found, a fine needle aspiration may be performed to evaluate whether the nodule is benign or malignant.
  • Adrenal Biopsy: For diagnosing adrenal masses, particularly in cases of suspected metastasis.

5. Genetic Testing:

Some endocrine disorders, such as Multiple Endocrine Neoplasia (MEN) syndromes or congenital adrenal hyperplasia, have a genetic basis. Genetic testing helps to confirm the diagnosis and guide family counseling.