Download History and Physical Examination

Chapter 43
Patient Assessment: Endocrine
System
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Endocrine Disorders
• Affect all body systems
• Signs and symptoms:
– Vital signs
– Energy level
– Fluid and electrolyte imbalances
– Heat and cold intolerance
– Weight changes
– Altered sleep patterns
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Question
• Antidiuretic hormone is secreted by:
– A. The thyroid gland
– B. The hypothalamus
– C. The pituitary gland
– D. The kidney
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Answer
• C. The pituitary gland
• Rationale: The posterior lobe of the pituitary stores and
secretes ADH (vasopressin) in response to serum
osmolality. Because the primary function of ADH is to
control water excretion by the kidney, attention must be
focused on the patient’s hydration status (manifests as
fluid volume excess or deficit) and serum and urine
osmolality to acquire information about the general
functioning of this part of the pituitary.
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The Hypothalamus and Pituitary Gland
• Hypothalamus controls pituitary gland hormones.
• Posterior lobe of the pituitary gland secretes ADH
(vasopressin).
• ADH controls water excretion by the kidney.
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History and Physical Examination
• Assess hydration.
• Skin turgor
• Buccal membrane moisture
• Vital signs
• Weight
• Intake and output
• Urine specific gravity
• Central venous pressure or pulmonary artery catheter
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Laboratory Studies
• Serum antidiuretic hormone
• Urine specific gravity
• Serum osmolality
• Urine osmolality
• Water deprivation test
• Antidiuretic hormone administration
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Comparison of Diabetes Insipidus and
SIADH
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Diagnostic Studies
• CT
• MRI
• Angiography
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The Thyroid Gland
• Thyroid hormones are regulated by hypothalamus and
pituitary gland.
• Negative feedback system
• Hyperthyroidism
–
Thyrotoxicosis
• Hypothyroidism
– Myxedema coma
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Question
• All of the following are signs of hypothyroidism except:
– A. Dry skin
– B. Husky voice
– C. Tachycardia
– D. Decreased deep tendon reflexes
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Answer
•
C. Tachycardia
•
Rationale: Hypothyroidism is frequently associated with
hypotension, bradycardia, hypoventilation, and
subnormal temperature. The patient often has dry, flaky
skin; edema over the pretibial area; and a deep or
husky voice. The patient displays slowed cognitive
functioning with slower-than-normal verbal responses,
slowed rapid alternating movements, and decreased
deep tendon reflexes.
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Hypothalamic–Pituitary–Thyroid Axis
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Signs of Hypothyroid and Hyperthyroid
States
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History and Physical Examination
• Inspect the anterior neck area for enlargement, nodules,
and symmetry of the gland.
• Observe the thyroid rise with swallowing.
• Palpate for size, shape, symmetry, and tenderness.
• Auscultate for thyroid bruit.
• Vital sign changes
• Skin changes (including edema)
• Neurological changes
• Weight changes
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Laboratory Studies
• Thyroid-stimulating hormone test (thyrotropin assay)
• Total thyroxine
• Free thyroxine and free thyroxine index
• Free triiodothyronine
• Triiodothyronine resin uptake test
• Calcitonin
• Thyroid antibodies
• Thyroglobulin
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Diagnostic Studies
• Thyroid scan
• Radioactive iodine uptake
• Fine needle biopsy
• Ultrasound
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The Parathyroid Gland
• Four parathyroid glands located just posterior to the
thyroid gland
• Produces parathyroid hormone (PTH)
• PTH is regulated by the serum level of calcium under a
negative feedback system.
• Maintains blood calcium and phosphorus levels
• Neuromuscular activity
• Blood clotting function
• Cell membrane permeability
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History and Physical Examination
• History of electrolyte imbalance, specifically related to
calcium and phosphorus
• Kidney stone symptoms
• Joint and bone pain
• Tetany
–
Trousseau’s sign or Chvostek’s sign
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Laboratory Studies
• Normal calcium levels range from 8.6 to 10.3 mg/dL.
• 99% of body calcium is in the bone; 1% is in the ECF.
• 50% of serum calcium is ionized or free.
• 50% is bound to albumin.
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Question
• Is the following statement true or false?
• Tetany is a result of hypocalcemia.
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Answer
• True
• Rationale: Hypocalcemia, as a result of
hypoparathyroidism, manifests neurologically as tetany
(general muscular hypertonia, tremor, and spasmodic
movements) when calcium levels dip below 5 to 6 mg/dL.
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Calcium
• Levels greater than 10.3 mg/dL = hyperparathyroidism
– Common causes include primary hyperparathyroidism,
malignancy, sarcoidosis, vitamin D toxicity,
hyperthyroidism, and some medications, such as
thiazide diuretics and lithium.
• Low calcium levels = hypoparathyroidism
– Tetany develops at calcium levels of 5 to 6 mg/dL or
lower.
– Common causes include hypoalbuminemia, renal failure,
hypoparathyroidism, acute pancreatitis, tumor lysis
syndrome, severe hypomagnesemia, and multiple
citrated blood transfusions.
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The Endocrine Pancreas
• Disorders characterized by
– Chronic hyperglycemia
– Major shifts of fluids and electrolytes
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History and Physical Examination
• Multisystem focused
• Family history
• Extent and duration of diabetes
• Onset of complications
• Medications
• Past medical and surgical history
• Chronic complications: neuropathy, retinopathy, and
nephropathy
• Related medical conditions: hypertension,
hyperlipidemia, obesity, and peripheral vascular disease
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Physical Examination
• Fluid status and hydration
• Skin turgor, buccal membranes
• Weight
• Urine specific gravity
• Vital signs
• Neurological status
• Central venous pressures
• Fruity odor on the breath (associated with ketonemia)
• Kussmaul’s respirations
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Laboratory Studies
• Fasting blood glucose level and fingerstick glucose
analysis
• Glycosylated hemoglobin
• Fructosamine
• Insulin
• C-peptide level
• Glucagon
• Serum ketones
• Urine ketones
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Question
• Is the following statement true or false?
• The outer cortex of the adrenal gland secretes
epinephrine.
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Answer
• False
• Rationale: The cortex produces mineralocorticoids (eg,
aldosterone), glucocorticoids (eg, cortisol), and
androgens. The medulla secretes catecholamines such as
epinephrine, norepinephrine, and dopamine.
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The Adrenal Gland
• Outer cortex
– Produces mineralocorticoids (eg, aldosterone),
glucocorticoids (eg, cortisol), and androgens
• Inner medulla
– Secretes catecholamines such as epinephrine,
norepinephrine, and dopamine
• Regulates fluid and electrolyte balance, sympathetic
nervous system responses, inflammation, and
metabolism
• Negative feedback system through the hypothalamic–
pituitary axis
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History and Physical Examination
• Sudden, severe headache
• Diaphoresis
• Palpitations
• Hypersecretion of ACT = Cushing’s syndrome
• Adrenal insufficiency = Addison’s disease
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Laboratory Studies
• Cortisol (hydrocortisone)
• Cortisol (dexamethasone) suppression
• Cortisol stimulation
• Urine and plasma catecholamine levels
• Urine 17-ketosteroids and 17-hydroxycorticosteroids
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Diagnostic Studies
• Adrenal scan
– Identifies the site of certain tumors or sites that
produce excessive amounts of catecholamines
– Radionuclide iobenguane (131I) is injected
intravenously, and scans are performed on days 2, 3,
and 4.
– Normally tumors and sites of hypersecretion are
absent.
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