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
References
- Bickley L, Szilagyi P. BATES’ Guide to Physical Examination and History Taking. 9th edition. Lipincott Williams & Wilkins; 2007.
- McGee, S. Evidence Based Physical Diagnosis 3rd edition. Philadelphia, PA. Elsevier; 2012.
- Siminoski, K. Does This Patient Have a Goiter? JAMA The Rational Clinical Examination. 1995; Vol 273, No. 10.
- 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.
- Gardner D, Shoback D. Greenspan’s Basic & Clinical Endocrinology. 8th Edition. USA. McGraw-Hill. 2007.
- Bastian L, Smith C, Nanda, K. Is this Woman Perimenopausal? JAMA The Rational Clinical Examination. 2003; Vol 289, No. 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.
- Hall J et al. Essentials of Clinical Examination Handbook 7th ed. New York, NY: TMSP, Thieme; 2013.
- Swartz, M. Textbook of Physical Diagnosis 6th ed. Philadelphia, PA. Saunders Elsevier; 2010.