OnExam

Vital Signs

Follow the directions for assessing the vital signs.

  • Hypertension seen in Cushing Syndrome:
      +LR 2.3, -LR 0.8
  • Inspection

    Stature and habitus of patient

    • Height, weight and BMI
    • Central obesity
      • Often present in diabetes mellitus and cushing syndrome
      • Accumulation of fat on the face, neck, chest, back and abdomen
      • +LR 3.0, -LR 0.2 (if it’s not present, Cushing’s is unlikely)
    • Buffalo hump (seen in Cushing syndrome)
    • Neck collar (seen in Cushing syndrome)
    • Dewlap on the sternum (corticosteroid-induced episternal fatty tumour)
    • Kyphosis (osteoporosis)

    Head and Neck

    • Complete Head and Neck Exam
    • Moon facies
      • +LR 1.6, -LR 0.1 (if it’s not present; Cushing’s is unlikely)
      • +LR 3.0, -LR 0.2 (if it’s not present, Cushing’s is unlikely)
    • Acromegaly
    • Webbed neck of Turner syndrome
    • Goiter
      • See Special Tests – thyroid examination.
      • Goiter present in 70-93% of patients with hyperthyroidism
        • Diffuse in Graves disease
        • Nodular in toxic nodular goiter
    • Plethora (abnormal diffuse purple or reddish colour of face seen in Cushing's)
    • +LR 2.7, -LR 0.3

    Skin and Hair

    • Pigment changes to skin or buccal surface
    • Acanthosis nigricans of neck or axillae (Seen in DM, PCOS, hypothyroidism, Cushing Syndrome)
    • Acne
      • +LR 2.2, -LR 0.5 (for Cushing’s syndrome)
    • Ecchymosis
      • +LR 4.5, -LR 0.5 (for Cushing’s syndrome)
    • Thinning of hair or eyebrows
    • Hirsutism
    • Cool and dry skin
      • +LR 4.7 (for hypothyroidism)
    • Coarse skin
      • +LR 3.4 (for hypothyroidism)
    • Check extremities for myxedema (Non-pitting “jelly like” edema, seen in hyperthyroidism)
    • Look for “puffiness”
    • Change in skin pigmentation
    • Yellow skin in hypothyroidism
    • Examine skinfold thickness
      • A thin skinfold < 1.8mm has a +LR 115.6, -LR 0.2 for Cushing's syndrome

    Eyes

    • Exophthalmos
      • +LR 31.5, -LR 0.7 for hyperthyroidism
    • Lid lag (van Graefe sign)
      • Appearance of white sclera between the upper eyelid and the central limbus as the patient looks downwards
      • +LR 17.6, -LR 0.8 for hyperthyroidism
    • Lid retraction (Dalrymple sign)
    • Graves opthalmopathy: lid edema, limitation of eye movements, conjunctival chemosis and injection, exopthalmos
    • Periorbital puffiness (hypothyroidism)
    • Fundoscopic examination for diabetic retinopathy
    • Examine visual fields by confrontation
    • Examine extraocular movements
    • Limited eye movements in hyperthyroidism

    Mouth and Pharynx

    • Look for pigmentation changes on buccal surfaces
    • Tongue enlargement
    • Speech or voice change
      • Hoarse voice in goiter, thyroid carcinoma
    • Tooth count: if fewer than 20 teeth, consider osteoporosis

    Chest, Abdomen and Pelvis

    • Gynecomastia
    • Lactorrhea
    • Change in nipple pigmentation
    • Change in amount or quality of chest hair
    • Striae on abdomen, thighs
    • Striae of Cushing’s syndrome are wide >1cm and deep purple to red
    • +LR 1.9, -LR 0.7
    • Central obesity
    • +LR 3.0, -LR 0.2
    • Genital atrophy
    • Ambiguous genitalia
    • Wall-Occiput distance
      • Inability to touch occiput to wall when standing with back and heels to wall
    • Rib-Pelvis distance
      • Less than two fingerbreadths between the inferior margin of the ribs and the superior surface of the pelvis and the midaxillary line

    Extremities

    • Oversized hands of acromegaly
    • Palmar erythema
    • Pigmentation changes
    • Bradydactyly (shortened fingers)
    • Shortened 4th and 5th can be seen in pseudohypoparathyroidism
    • Nail changes
    • Edema
    • +LR 1.8, -LR 0.7
    • Tremor

    Auscultation

    • Listen over thyroid for bruits and flow murmurs. See section on the thyroid exam
    • Listen for bruits suggesting severe atherosclerosis in carotid, renal, femoral arteries
    • Patients with diabetes are at risk of macrovascular complications including stroke and heart attacks
    • Auscultate heart for evidence of cardiovascular disease which may be related to the endocrine system
      • Midsystolic flow murmur
      • Supraventricular arrhythmias
      • Rarely, Means-Lerman scratch: a systolic rub or murmur with a prominent grating character
      • Loud snapping first heart sounds in hyperthyroidism
      • Flow murmurs and supraventricular arrhythmias in hyperthyroidism

    Palpation

    • Palpate the thyroid. See section on the thyroid exam
    • Examine muscle strength
    • Check reflexes
      • Hyperreflexia may indicate diabetes insipidus
      • Hyporeflexia in hypothyroidism
    • Palpate to assess for tachycardia or bounding pulse
    • Palpate to assess for peripheral muscular weakness
    • Assess reflexes
      • Brisk achilles and other reflexes in 25% of patients with hyperthyroidism

    Diabetes Mellitus

    • In patients with current diabetes, perform history and physical examination to screen for long term complications
    • Assess for

    • Current glycemic control
    • Home blood sugar trends
    • Ask patient about current medications
    • Ask patient about glucose readings at home
    • Ask about diet and exercise
    • When appropriate, check patients random blood sugar
    • Compare home monitor to clinic monitor annually
    • Macrovascular complications
    • Peripheral vascular complications
    • Cerebrovascular complications
    • Examine for

    • Microvascular complications
      • Retinopathy
        • Ophthalmoscope examination of retina for diabetic retinopathy
          • Non-proliferative diabetic retinopathy: Intraretinal hemorrhages, cotton wool exudates
          • Proliferative diabetic retinopathy: Neovasularization creates a fine network of blood vessels with preretinal hemorrhages
        • Ask if patient has regular optometrist appointments
      • Nephropathy
        • Check for proteinuria as a screening method for chronic kidney disease
      • Enquire about erectile dysfunction
    • Neuropathy
      • Ask if patient notices any burning, tingling, or decreased sensation in feet
      • Monofilament test of feet
      • Check feet – See the diabetic foot exam
      • Ulcerations
      • Charcot foot
      • Sensation with 10g monofilament
    • Psychological complications
      • Screen for depression

    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 3rd edition. Philadelphia, PA. Elsevier; 2012.
    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.
    8. Hall J et al. Essentials of Clinical Examination Handbook 7th ed. New York, NY: TMSP, Thieme; 2013.
    9. Swartz, M. Textbook of Physical Diagnosis 6th ed. Philadelphia, PA. Saunders Elsevier; 2010.