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
- Night sweats
- Vaginal dryness
- Variable sexual interest
- Dyspareunia
- Urinary incontinence
- Depressed mood
- Nervous tension and/or irritability
- Sleep disturbances
Osteoporosis
- Height loss
- Self reported humped back
- Low weight
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
- Hypothyroidism
- 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
Review of Systems
Conduct a review of systems, keeping other etiologies from your differential in mind.
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. St. Louis Missouri. Saunders Elsevier. 2007.
- 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.