retinopathy (fundoscopy) and nephropathy (test urine for microalbuminuria).
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Common presenting symptoms 212
Female reproductive system 216
Common presenting symptoms 217
Obstetric history and examination: the booking visit 225
Drug, alcohol and smoking history 225
Routine antenatal check in later pregnancy 226
Common presenting symptoms 226
Common presenting symptoms 231
OSCE example 1: Breast examination 236
OSCE example 2: Scrotal pain history 236
The breasts are modified sweat glands. The openings of
the lactiferous ducts are on the apex of the nipple, which is
erectile tissue. The nipple is in the fourth intercostal space in
the mid-clavicular line, but accessory breast/nipple tissue may
develop anywhere down the nipple line (axilla to groin) (Figs 11.1
and 11.2). The adult breast is divided into the nipple, the areola
and four quadrants (upper outer to lower inner), with an axillary tail
(of Spence) projecting from the upper outer quadrant (Fig. 11.3).
The size and shape of the breasts are influenced by age,
hereditary factors, sexual maturity, phase of the menstrual cycle,
parity, pregnancy, lactation and nutritional state. Fat and stroma
surrounding the glandular tissue determine the size of the breast,
except during lactation, when enlargement is mostly glandular. The
breast responds to fluctuations in oestrogen and progesterone
levels. Swelling and tenderness are common in the premenstrual
phase. The glandular tissue reduces and fat increases with age,
making the breasts softer and more pendulous. Lactating breasts
are swollen and engorged with milk, and are best examined
Benign and malignant conditions of the breast cause similar
symptoms but benign changes are much more common. The
most common presenting symptoms are a breast lump, breast
pain, and skin and nipple changes. Men may present with
gynaecomastia (breast swelling). Women are often worried that
they have breast cancer, whatever breast symptom they have,
and it is important to explore these concerns.
The history of the presenting symptoms is crucial. Find out
the nature and duration of symptoms, any changes over time
and any relationship to the menstrual cycle.
Ask about risk factors for breast cancer, in particular:
• previous personal history of breast cancer
• family history of breast or ovarian cancer and the age of
• use of hormone replacement therapy
• previous mantle radiotherapy for Hodgkin’s lymphoma.
Not all patients have symptoms. Women may present with an
abnormality on screening mammography or concerns about
• Is it a single lump or multiple lumps?
Fig. 11.1 Accessory breast tissue in the axilla.
Fig. 11.2 Cross-section of the female breast.
The physical examination • 203
10.4 Adrenal causes of endocrine hypertension
Condition Hormone produced in excess Associated features
Conn’s syndrome Aldosterone Hypokalaemia
skin thinning, violaceous striae, hypokalaemia
Phaeochromocytoma Noradrenaline (norepinephrine),
Paroxysmal symptoms, including hypertension, palpitations, sweating
insufficiency, the pituitary increases ACTH secretion in
response to low cortisol levels. High levels of ACTH increase
melanocyte-stimulating hormone, leading to increased skin
pigmentation (most striking in white Caucasians). Vitiligo
(depigmentation of areas of skin) occurs in 10–20% of
Addison’s disease cases (Fig. 10.12A).
• Measure the blood pressure and test for postural
hypotension (p. 51), resulting from salt and water loss due
to inadequate mineralocorticoid.
• Look for signs of weight loss.
• Examine the skin for abnormal or excessive pigmentation.
This is most prominent in sun-exposed areas or epithelia
subject to trauma or pressure: skin creases, buccal mucosa
(Fig. 10.12B) and recent scars. In primary adrenal
The gonads (testes and ovaries) secrete sex hormones
(testosterone and oestrogen) in response to gonadotrophin
(FSH and LH) release by the pituitary. The reproductive system
Most commonly, men present with androgen deficiency, whereas
women present with hyperandrogenism.
Hypogonadism can be primary (failure of the gonad itself) or
secondary (where reduced gonadotrophin levels cause gonadal
failure). Klinefelter’s syndrome (47XXY) is the most common cause
of primary hypogonadism in men (1:600 live male births; Fig.
10.13). Secondary hypogonadism may be caused by pituitary
disease, extremes of weight, or drugs that suppress hypothalamic
gonadotrophin releasing hormone release (such as anabolic
steroids or opiates). Presenting symptoms in men include loss
of libido, erectile dysfunction, loss of secondary sexual hair,
reduction in testicular size and gynaecomastia (p. 214).
Hyperandrogenism in women usually presents with hirsutism
(excessive male-pattern hair growth; Fig. 10.14), acne and/or
oligomenorrhoea, and is commonly due to polycystic ovarian
syndrome (PCOS; usually also associated with obesity).
Other less common causes should be considered (such as
congenital adrenal hyperplasia). Virilisation is suggested by
male-pattern baldness, deepening of the voice, increased
muscle bulk and clitoromegaly; if present in women with a short
history of severe hirsutism, consider a testosterone-secreting
• thirst: due to the resulting loss of fluid
• weight loss: due to fluid depletion and breakdown of fat
and muscle secondary to insulin deficiency.
Other common symptoms are tiredness, mood changes and
blurred vision (due to glucose-induced changes in lens refraction).
Bacterial and fungal skin infections are common because of the
combination of hyperglycaemia, impaired immune resistance
and tissue ischaemia. Itching of the genitalia (pruritus vulvae in
women, balanitis in men) is due to Candida yeast infection (thrush).
Past medical, drug, family and
• Previous glucose intolerance or gestational diabetes, which
are risk factors for progression to type 2 diabetes.
• Other autoimmune conditions such as thyroid disease
(increased incidence of type 1 diabetes).
• Drug therapy: glucocorticoids can cause steroid-induced
• Family history of diabetes or autoimmune disease.
Monogenic diabetes is usually inherited in an autosomal
dominant manner. Patients are often slim (unlike those with
type 2 diabetes) but do not require insulin at diagnosis (unlike
those with type 1 diabetes). Monogenic diabetes should be
considered in people presenting with diabetes under the age
of 30 who have an affected parent or a family history of
early-onset diabetes in around 50% of first-degree relatives.
• Smoking habit: combines with diabetes to increase the
risk of vascular complications.
• Alcohol: raises the possibility of pancreatic diabetes.
Fig. 10.13 Klinefelter’s syndrome. Tall stature, gynaecomastia, reduced
The pancreas lies behind the stomach on the posterior abdominal
wall. Its endocrine functions include production of insulin (from beta
cells), glucagon, gastrin and somatostatin. Its exocrine function
is to produce alkaline secretions containing digestive enzymes.
Diabetes mellitus is characterised by hyperglycaemia caused
by absolute or relative insulin deficiency.
Diabetes may be primary or secondary. Primary diabetes is
• type 1: severe insulin deficiency due to autoimmune
destruction of the pancreatic islets. These patients are
susceptible to acute decompensation due to hypoglycaemia
or ketoacidosis, both of which require prompt treatment.
• type 2: commonly affects people who are obese and
insulin-resistant, although impaired beta-cell function is
also important. These patients may decompensate by
developing a hyperosmolar hyperglycaemic state.
Secondary causes of diabetes and the associated history and
examination features are described in Box 10.5.
Diabetes mellitus commonly presents with a classical triad of
• polyuria (and nocturia): due to osmotic diuresis caused by
Assessment of a patient with newly
• Look for evidence of weight loss and dehydration.
Unintentional weight loss is suggestive of insulin deficiency.
• Check for clinical features of acromegaly or Cushing’s
• Look for Kussmaul respiration (hyperventilation with a
deep, sighing respiratory pattern) or the sweet smell of
ketones, both of which suggest insulin deficiency and
• Skin: look for signs of infection such as cellulitis, boils,
abscesses and fungal infections, paying particular attention
to the feet (see later). Look for signs of insulin resistance
such as acanthosis nigricans (Fig. 10.15A). Necrobiosis
lipoidica, a yellow, indurated or ulcerated area surrounded
by a red margin indicating collagen degeneration (Fig.
10.15B), may occur on the shins in type 1 diabetes and
often causes chronic ulceration.
• Look for xanthelasmata and xanthomata (Fig. 10.15C; see
Fig. 4.6); these are suggestive of dyslipidaemia, which may
• Measure the pulse and blood pressure, and examine the
cardiovascular and peripheral vascular systems, with a
particular emphasis on arterial pulses in the feet (p. 69).
• Examine the central nervous system, with a particular
focus on sensation in the lower limbs (p. 143).
• Test visual acuity and perform fundoscopy (p. 164; see
• Perform urinalysis for glycosuria.
Microvascular, neuropathic and macrovascular complications
of hyperglycaemia can occur in patients with any type of diabetes
mellitus, and may be present at diagnosis in patients with
Glycosuria is in keeping with diabetes; the presence of urinary
(or blood) ketones suggests insulin deficiency and the possibility
of diabetic ketoacidosis. Other investigations to consider are
In established diabetes, vital aspects of the history (Box
10.6) and examination should be reviewed at least once
The physical examination will differ, depending on whether this
is a new presentation of diabetes or a patient with established
diabetes attending for their annual review.
10.6 Routine history taking as part of the annual
• Ask about frequency of blood glucose testing and frequency and
awareness of symptoms of hypoglycaemia
• When relevant, give guidance on driving and/or pre-pregnancy
• Enquire about any lumpiness (lipohypertrophy), bruising or
Symptoms of macrovascular disease
• Ask whether there has been any angina, myocardial infarction,
claudication, stroke or transient ischaemic attack since the last
Symptoms of microvascular disease
• Ask whether there has been any change in vision or any numbness
or altered sensation in the feet
• Ask about neuropathy and peripheral vascular symptoms as above
• Enquire about any breaks in the skin, infections or ulcers
• Enquire about erectile dysfunction in men
• Ask about postural hypotension, sweating, diarrhoea and vomiting in
10.5 Causes of secondary diabetesa
Cause of diabetes Examples Clinical features
Pancreatic disease Pancreatitis Abdominal pain
Trauma/pancreatectomy Surgical scar
Cystic fibrosis Chronic cough, purulent sputum
Haemochromatosis Skin pigmentation (‘bronze diabetes’)
Endocrinopathies Acromegaly, Cushing’s syndrome p. 202
Drugs Glucocorticoids (e.g. prednisolone)
Antipsychotics (e.g. olanzapine)
Features of Cushing’s syndrome (see Fig. 10.11)
Immunosuppressants (e.g. ciclosporin, tacrolimus) Gum hypertrophy may be seen with ciclosporin use
Pregnancy Gestational diabetes may develop in the third trimester Gravid uterus
Glucokinase deficiency Glucokinase deficiency is present from birth with
Based on classification by the American Diabetes Association.
The physical examination • 207
Up to 40% of people with diabetes have peripheral neuropathy and
40% have peripheral vascular disease, both of which contribute
to a 15% lifetime risk of foot ulcers (Fig. 10.16).
Early recognition of the ‘at-risk’ foot is essential. There are
• Neuropathic: neuropathy predominates but the major
• Neuroischaemic: reduced arterial supply produces
ischaemia and exacerbates neuropathy.
Infection may complicate both presentations.
• Look for hair loss and nail dystrophy.
• Examine the skin (including the interdigital clefts) for
excessive callus, skin breaks, infections and ulcers. Look
for any discoloration. Distal pallor can suggest early
ischaemia, while purple/black discoloration suggests
• Ask the patient to stand so that you can assess the foot
arch; look for deformation of the joints of the feet.
• Feel the temperature of the feet.
• Examine the dorsalis pedis and posterior tibial pulses. If
absent, arrange Doppler studies and evaluate the
ankle:brachial pressure index (p. 69).
• Test for peripheral neuropathy: use a 10-g monofilament
to apply a standard, reproducible stimulus. The technique
Routine review of a patient with diabetes
• Weigh the patient: weight gain in type 2 diabetes is likely
to be associated with worsening insulin resistance while
weight loss in type 1 diabetes often suggests poor
glycaemic control and inadequate insulin dosage.
• For patients on insulin, examine insulin injection sites for
evidence of lipohypertrophy (which may cause
unpredictable insulin release), lipoatrophy (rare) or signs of
• Measure the pulse and blood pressure.
• Test visual acuity and perform fundoscopy (p. 164; see
• Examine the feet (see the next section).
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