OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint or reason for visit.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

  • Ask specifically about those symptoms pertaining to the endocrine system

  • Hyperthyroidism

    • Weight loss
    • Anxiety
    • Diaphoresis
    • Heat intolerance
    • Palpitations
    • Amenorrhea
    • Tremor
    • Increased appetite
    • Frequent bowel movements
    • Proximal muscle weakness

    Hypothyroidism

    • Fatigue
    • Weight gain
    • Anorexia
    • Dry, coarse skin
    • Cold intolerance
    • Constipation
    • Weakness, muscle cramps, arthralgia
    • Impaired memory
    • Depressed mood
    • Hearing change
    • Diminished sweating
    • Voice hoarseness
    • Brittle, breaking hair

    Diabetes Mellitus

    • Diagnostic Symptoms
      • Polyuria
      • Polydipsia
      • Polyphagia with weight loss
      • Fatigue
      • Vision change
      • Paresthesia or numbness in extremities
      • Nocturnal enuresis
      • Vulvovaginitis/pruritis
    • Screening for complications
      • Retinopathy: any change in vision, most recent optometric visit
      • Autonomic neuropathy: symptoms of gastroparesis, urinary retention, erectile dysfunction
      • Peripheral neuropathy: burning/tingling in hands or feet, poorly healing feet ulcers, decreased sensation
      • Macrovascular complications: chest pain, dyspnea, claudication, TIA/stroke
      • Psychological complications: screen for depression
    • Monitoring Control
      • Ask about current glycemic control, home glucose monitoring, blood sugar trends, diet and exercise
      • Calibrate home glucometer annually
      • Complete periodic medication reconciliations

    Diabetes Insipidus

    • Diagnostic Symptoms
      • Significant Polyuria 3-20L qDaily
      • Polydipsia
      • Nocturia
      • Dehydration
      • Irritability
      • Lethargy
      • Weakness
      • Muscle twitching
      • Seizures

    Cushing's Syndrome

    Note: Cushing syndrome is a disease caused by the overproduction of adrenocorticotropic hormone by the pituitary gland or ingestion of exogenous corticosteroids. Cushing’s Syndrome presents with a constellation of: hypertension, central obesity, weakness, hirsutism, depression, striae, and ecchymosis

    • Diagnostic Symptoms
      • Fatigue
      • Weight gain
      • Muscle weakness
      • Hirsutism
      • Depression
      • Striae formation
      • Unexplained eccymosis or easy bruising
      • Hypertension

    Adrenal Insufficiency

    • Hyperpigmentation
    • Primary adrenal insufficiency – Addison’s disease
    • Weakness
    • Fatigue
    • Anorexia
    • Nausea and vomiting
    • Hypotension
    • Salt craving
    • Syncope

    Perimenopause/Menopause

    • Findings with the best ability to rule in perimenopause are hot flashes, night sweats, and vaginal dryness
    • Hot flashes
      • +LR 2.0, -LR 0.5
    • Night sweats
      • +LR 2.0, -LR 0.7
    • Vaginal dryness
      • +LR 2.0
    • Variable sexual interest
    • Dyspareunia
    • Urinary incontinence
    • Depressed mood
    • Nervous tension and/or irritability
    • Sleep disturbances

    Osteoporosis

    • Height loss
      • +LR 3.0, -LR 0.4
    • Self reported humped back
      • +LR 3.0
    • Low weight
      • +LR 7.3

    Polycystic Ovarian Syndrome (PCOS)

    • Irregular menstrual cycles (oligomenorrhea, amenorrhea)
    • Acne
    • Hirsutism
    • Weight gain
    • Infertility
    • Diabetes Mellitus

    Past Medical History (PMHx)

    Specifically ask:

    • General history of previous illnesses, conditions, and hospitalizations
    • Current or recent pregnancy
      • Gestational diabetes
      • Thyroiditis
    • Autoimmune conditions
    • Congenital problems
    • Renal calculi
    • Parathyroid conditions
    • Pituitary conditions
    • Menopause
    • HIV infection – can sometimes have findings that mimic those of Cushing's
    • Granulomatous diseases such as tuberculosis, sarcoidosis, histiocytosis
      • Can be a secondary cause of diabetes insipidus
      • History of fractures may be present

    Surgical History

    • Hysterectomy and oophorectomy status
    • Thyroidectomy or radiation treatment

    Note: Consider traumatic head injury as a possible cause for pituitary abnormalities

    Family History (FmHx)

    Specifically ask about:

    • Marfan’s syndrome
    • Diabetes mellitus
    • Hyperthyroidism
      • Grave’s Disease
    • Hypothyroidism
      • Hashimoto’s thyroiditis
    • Osteoporosis
    • Menopause
      • Age of onset of menopause in mothers/sisters menopause

    Social History (SocHx)

    Specifically ask about:

    • Occupation
    • Workplace exposures
    • Home living conditions

    Substance Use History (SubHx)

    Specifically ask about:

    Medications

    • Ask about all medications patient is currently taking
    • Specifically those pertaining to endocrine system
      • Recent use of steroids including inhaled and oral
      • Hormone replacement therapy (HRT)
      • Oral contraceptive pills
      • Thyroid replacement therapy
      • Diabetes medications
        • If relevant, ask if they have any hypoglycemic episodes
      • Bisphosphonates for osteoporosis
    • Herbal Supplements
      • Health food hormone supplements
      • “Diet” pills including those containing hormones or epinephrine

    Allergies

    Note allergies and ensure they concord with those listed in the EMR

    Immunizations

    Note immunization history as described in the immunization history section

    Review of Systems

    Conduct a review of systems, keeping other etiologies from your differential in mind.

    References

    1. Bickley L, Szilagyi P. BATES’ Guide to Physical Examination and History Taking. 9th edition. Lipincott Williams & Wilkins; 2007.
    2. McGee, S. Evidence Based Physical Diagnosis. St. Louis Missouri. Saunders Elsevier. 2007.
    3. Siminoski, K. Does This Patient Have a Goiter? JAMA The Rational Clinical Examination. 1995; Vol 273, No. 10.
    4. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008; 32(suppl 1): S1-S201.
    5. Gardner D, Shoback D. Greenspan’s Basic & Clinical Endocrinology. 8th Edition. USA. McGraw-Hill. 2007.
    6. Bastian L, Smith C, Nanda, K. Is this Woman Perimenopausal? JAMA The Rational Clinical Examination. 2003; Vol 289, No. 7.
    7. Green A, Colon-Emeric C, Bastian L, et al. Does this Woman have Osteoporosis? JAMA The Rational Clinical Examination. 2004; Vol 292, No. 23.