Examination sequence

• Look for periorbital puffiness or oedema, and lid

retraction (this is present if the white sclera is visible

above the iris in the primary position of gaze; see

Fig. 10.2A).

• Examine for features of Graves’ ophthalmopathy, including

exophthalmos (look down from above and behind the

patient), lid swelling or erythema, and conjunctival redness

or swelling (chemosis).

• Assess for lid lag: ask the patient to follow your index

finger as you move it from the upper to the lower part of

the visual field. Lid lag means delay between the

movement of the eyeball and descent of the upper eyelid,

exposing the sclera above the iris.

10.3 Investigations in thyroid disease

Investigation Indication/comment

Biochemistry

Thyroid function tests To assess thyroid status

Immunology

Antithyroid peroxidase antibodies Non-specific, high in autoimmune

thyroid disease

Antithyroid stimulating hormone

receptor antibodies

Specific for Graves’ disease

Imaging

Ultrasound Goitre, nodule

Thyroid scintigraphy (123I, 99mTc) To assess areas of hyper-/

hypoactivity

Computed tomography To assess goitre size and aid

surgical planning

Invasive/other

Fine-needle aspiration cytology Thyroid nodule

Respiratory flow-volume loops To assess tracheal compression

from a large goitre

THE PARATHYROIDS

Anatomy and physiology

There are usually four parathyroid glands situated posterior to

the thyroid (see Fig. 10.1A). Each is about the size of a pea

and produces parathyroid hormone, a peptide that increases

circulating calcium levels.

The history

Common presenting symptoms

Parathyroid disease is commonly asymptomatic. In hyperparathyroidism the most common symptoms relate to hypercalcaemia:

polyuria, polydipsia, renal stones, peptic ulceration, tender areas

of bone fracture or deformity (‘Brown tumours’: Fig. 10.6A),

and delirium or psychiatric symptoms. In hypoparathyroidism,

hypocalcaemia may cause hyper-reflexia or tetany (involuntary

muscle contraction), most commonly in the hands or feet.

Paraesthesiae of the hands and feet or around the mouth may

occur. Hypoparathyroidism is most often caused by inadvertent

damage to the glands during thyroid surgery but may also be

caused by autoimmune disease. Patients with the rare autosomal

dominant condition pseudohypoparathyroidism have end-organ

resistance to parathyroid hormone and typically have short stature,

a round face and shortening of the fourth and fifth metacarpal

bones (Fig. 10.6B,C).

The physical examination • 199

10

• Examine the neck for scars. Parathyroid tumours are very

rarely palpable.

• Measure the blood pressure and assess the state

of hydration (p. 244). Inflating the blood pressure cuff

in a patient with hypocalcaemia may precipitate carpal

muscle contraction, producing a typical picture with

the thumb adducted, the proximal interphalangeal

and distal interphalangeal joints extended and the

metacarpophalangeal joints flexed (‘main d’accoucheur’,

hand of the obstetrician, or Trousseau’s sign;

Fig. 10.7).

• Test for muscle weakness and hyper-reflexia (p. 138).

• Look for evidence of recent fractures or bone deformity/

tenderness.

• Perform urinalysis (renal stones may result in

haematuria).

Ask about:

• polyuria, polydipsia (hypercalcaemia)

• abdominal pain or constipation (hypercalcaemia)

• confusion or psychiatric symptoms (hypercalcaemia)

• bone pain (hypercalcaemia)

• muscle cramps, perioral or peripheral paraesthesia

(hypocalcaemia).

Past medical, drug, family and

social history

Ask about:

• recent neck surgery or irradiation

• past history of bone fractures

• past history of renal stones

• family history of hyperparathyroidism (which can be part of

the autosomal dominant multiple endocrine neoplasia

syndrome) or other endocrine disease (Addison’s disease

and type 1 diabetes can be associated with

hypoparathyroidism as part of the autosomal recessive

type 1 autoimmune polyglandular syndrome).

The physical examination

Examination sequence

• Hands: ask the patient to make a fist and assess the

length of the metacarpals (in pseudohypoparathyroidism

the metacarpals of the ring and little fingers are shortened;

Fig. 10.6B,C).

A

B

C

Fig. 10.6 Parathyroid disease. A Well-defined lucent lesion with surrounding sclerosis within the shaft of the third metacarpal of the right hand (arrow),

in keeping with a Brown tumour. B Pseudohypoparathyroidism: short fourth and fifth metacarpals. C These are best seen when the patient makes a fist.

(A) Courtesy of Dr Dilip Patel.

Fig. 10.7 Trousseau’s sign.

200 • The endocrine system

or headache due to expansion of the sella. Adenomas may

produce hormones such as prolactin, GH or ACTH; the resulting

symptoms and signs will depend on the excess hormone

present.

Prolactinoma

Ask about:

• galactorrhoea (breast milk secretion)

• oligomenorrhoea, amenorrhoea or infertility (in women)

• reduced libido, erectile dysfunction and reduced shaving

frequency (in men).

Acromegaly

GH excess prior to puberty presents as gigantism; after puberty,

it causes acromegaly.

Ask about:

• headache

• excessive sweating

• changes in facial features (ask to see old

photographs)

• an increase in shoe, ring or glove size

• associated medical conditions: arthropathy, carpal tunnel

syndrome, hypertension, diabetes, colonic malignancy,

sleep apnoea.