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Endocrinology Histories Laulwa Al Salloum, 4 year medical student 2367445A@student.gla.ac.ukWHAT WE’RE COVERING TATT Common endocrine histories Polydipsia Sweating / Weight changes Clinical Reasoning A little rheumatology (if we have time)EXAMPLE INSTRUCTIONS YOUR HISTORY WORKFLOW Introduction PC HPC WINDEC (establish why (WADIP - the bulk Systemic enquiry they’re there) of your marks) WADIP When, Acute/chronic, Duration, Intensity, ICE Summary Progression PMH + PSH SH FH DH (ask relevant Qs)INTRODUCTION - WINDEC • Wash hands • Introduce yourself • confirm Name, and • Date of birth • Explain what you’re going to do • Consent THE REST OF YOUR HISTORY Presenting complaint – next slides Drug History: • Medications they’re taking + if anything over History of presenting complaint the counter • Bulk of your marks • A framework is important • Allergies, allergies, allergies + what happens • WADIP: When, Acute/chronic, Duration, Intensity, Progression • Apply SOCRATES (it helps) Family History • Any family history of endocrine conditions • Exacerbating / Relieving factors • If diabetes, consider autoimmune links • Use this time to explore your differentials • If malignancy, ask about cancer (I always ask this) Past medical history • Has this happened before? Social History • Ask about surgical history – don’t forget this • Habits = Smoking, alcohol, recreational drugs • Lifestyle = Impact on their life, Mobilizing?, • (ask directlyen don’t think of diabetes, HTN, cholesterol – Housing, Diet THE REST OF YOUR HISTORY Systems Review • ALWAYS ALWAYS ask your red flags • Fever • Weight loss • Nausea • Night sweats • Work head to toe and apply what’s applicable • GI: bowels, abdominal discomfort • GU: urinary habits, blood in urine, menstrual cycle • Neuro: dizziness, visual changes, changes in sensation, headaches • If relevant, ask about pregnancy and sexual activityPRESENTING COMPLAINTSPOLYURIA POLYDIPSIA History of presenting complaint Systemic enquiry Past medical history • Establish onset and duration • Establish if drinking water helps Red flags: • Any coeliacs / thyroid issues? • Have they experienced this before; Did it • Fever, nausea, weight start suddenly or gradually loss Investigating Addisons General systems review Family History • Any appetite changes? • Any new cravings for salt? • Dizziness • Urinary symptoms • Family history of diabetes? If so, what age Investigating diabetes: • Bowel changes? • Polyuria? • Neuro symptoms • Family history of autoimmune disease? (RA / Graves / etc.) • Nocturia? • Weight loss? Rule out complications • Fatigue? • Eyes, feet, kidneys Investigating diabetes insipidus: • Recent head trauma?TIRED ALL THE TIMETIRED ALL THE TIME – possible differentials? (1 min) Mood - Depression Sleep – Are they sleeping well? Thyroid - Hypothyroidism Endocrine disorders - Addisons Pancreas - DiabeteLOTS OF THINGS MAKE YOU TIRED Malignancy - Cancer Recent illness Anaemia – menorrhagia, pallor TIRED ALL THE TIME – History of presenting complaint Systemic Enquiry History of presenting complaint Red flags • Establish duration and onset • Fever, weight loss, nausea • Establish character (what do they mean by tired) Associated symptoms – dependent on their presentation • If suspecting hypothyroid = sweating, tremor • Exacerbating / Relieving factors • If suspecting diabetes = polydipsia, polyuria, nocturia • Does sleeping more help? • If suspecting bleeding = blood in urine/stool, menorrhagia • Does it prevent them from doing General: ADLs? • ”Now I’m going to ask you a few • Neurology yes or no questions” • Change in bowel habit • Flu-like symptoms • Symptoms of pregnancy (if biologically female)TIRED ALL THE TIME – History of presenting complaint M = Mood • Depression, anxiety A = Appetite Bleed • Polydipsia = Diabetes • Salt cravings = Addisons • Menorrhagia • Menopause S = Sleep MASS Bleed • Pallor = Anaemia • Snoring = OSAS • Malignancy • Sleep hygiene S = Skin • Skin pigmentation = Addisons • Pallor = Anaemia • Dry skin = Hypothyroidism TIRED ALL THE TIME – History of presenting complaint History of presenting complaint Systemic Enquiry • Establish duration and onset Red flags • Establish character (what do they • Fever, weight loss, nausea mean by tired) Associated symptoms – dependent on their presentation • Exacerbating / Relieving factors • If suspecting hypothyroid = sweating, tremor • Does sleeping more help? • If suspecting diabetes = polydipsia, polyuria, nocturia • If suspecting bleeding = blood in urine/stool, menorrhagia • Does it prevent them from doing ADLs? General: • ”Now I’m going to ask you a few yes or no questions” • Neurology • Change in bowel habit (constipation) • Flu-like symptoms • Symptoms of pregnancy (if biologically female) CONDITIONS THAT CAN CAUSE TATT Condition How would it present? Depression Low mood, anhedonia Poor sleep, lack of energy Suicide ideation Hypothyroidism Constipation Weight gain Cold intolerance Diabetes Polydipsia, Polyuria, Nocturia Weight loss Visual disturbance Sleep apnoea Loud snoring Night time breathing interrupted by gasping Excessive daytime sleepiness Anaemia Exertional SOB Weakness PallorSWEATING / WEIGHT CHANGES SWEATING / WEIGHT CHANGES History of presenting complaint Realistically, this is going to be a thyroid condition, but we need to exclude malignancy with weight loss • Establish duration + onset • Confirm PC and establish character • Sweating: how much, how often? • Weight loss: amount of weight lost, over what period of time? • Exclude malignancy • Fatigue and loss of appetite (appetite increased in hyperthyroidism) • Establish thyroid condition • Hyperthyroidism: tremor, irritability, sweating, heat intolerance, palpitations, amenorrhoea/oligomenorrhoea, loss of libido, altered mental state, anxiety • Hypothyroidism: weight gain, lethargy, cold intolerance, bradycardia, etc. • Any neck swelling? (goitre) • Any visual changes/blurring (Graves) CONDITIONS THAT CAN CAUSE WEIGHT LOSS Condition How would it present? Malignancy Tumour symptoms (Lumps –breast, tesitcular; Haemoptysis in lung, Prostate symptoms; Bowel habit changes; Haematuria - TCC; Jaundice – head of pancreas Ca; Post-meno bleed - uterine) Colon cancer Elderly; Blood/malaena; Change in bowel habit Coeliac’s disease Diarrhoea, steatorrhoea Timing – when eating bread, etc. Abdominal discomfort Thyrotoxicosis Diarrhoea; Heat intolerance; Irritability; Oligmenorrhoea/Amenorrhoea Psychological Would be mean at this stage But depression; bulimia nervosa; anorexia; stress CLINICAL REASONING (a little interactive session)GENERAL TIPS • Know your big conditions, if you can DASPITE it then it’s fair game • Hypo/Hyperthyroidism, Diabetes, Cushings, Addisons • Get comfortable with interpreting bloods • Not just reading out but making sure you’re applying them clinically • What investigations you should perform • Always think of the setting you’re in • If you’re at GP, you won’t be performing a thyroid USS • Keep patient age in mind SPOT DIAGNOSES Presenting complaint Diagnosis A 20-year-old woman presents to the GP practice complaining of feeling thirstier ? recently and more tired. On questioning you find that she has been getting up at night to use the bathroom and is using the bathroom more in general. She also thinks she has been looking a little paler. Her mother has Grave’s disease. EXAMPLE QUESTIONS From the history, what is your diagnosis? You are given a set of bloods from her • Type 1 Diabetes recent visit to the GP. It shows that she has positive IgA anti-tTG. What is a reasonable differentials? What does this mean? What is the • Anaemia significance of this? Name three things from the history that support your • She has Coeliacs disease diagnosis? • Further supports the diagnosis of T1DM – autoimmune link • Polyuria, polydipsia • Nocturia • Young age + first presentation • Autoimmune link (mother has Graves’) SPOT DIAGNOSES Presenting complaint Diagnosis A 20-year-old woman presents to the GP practice complaining of feeling thirstier Type 1 Diabetes recently and more tired. On questioning you find that she has been getting up at night to use the bathroom and is using the bathroom more in general. She also thinks she has been looking a little paler. Her mother has Grave’s disease. A 35-year-old woman presents to the GP practice complaining of fatigue and weight Hypothyroidism gain despite being on a diet. She feels as though her hair has been getting dryer as well but is attributing it to the weather changing. You discover that she is feeling cold despite having the heating on constantly A 40-year-old woman with rheumatoid arthritis presents with 10g weight gain, Cushing’s Syndrome localized centrally. She reports increased facial hair and acne, as well as polyuria and polydipsia. You notice she is waddling into the GP practice. A 60-year-old presents to the GP practice feeling unwell. He has recently lost a lot of Bowel cancer weight, having to downsize two trouser sizes but attributed it to the recent chest infection he had. He has been having issues with his bowels.RHEUMA TOLOGY: PAINFUL JOINTS PAINFUL JOINTS History of presenting complaint Systemic Enquiry • SOCRATES Red flags • Fever, weight loss, nausea • Establish duration and onset • Timing Ruling out differentials: • <30 mins: osteoarthritis • >30 mins: inflammatory • Red eyes; Dry eyes/mouth (Sjogren’s) • Diarrhoea (Enteropathic arthritis) • Establish pattern • Mouth/genital ulcers (SARA) • Symmetrical; Small joints; Large joints; Single joint • Bleeding per rectum • Joint swelling + their distribution • Neurological symptoms • Stiffness after cold weather (Raynauds) • Joint stiffness? • Diurnal variation? • Skin and nail changes/Rashes/Plaque formation (Psoriatic arthritis) • Exacerbating / Relieving factors • Heat or activity? • Any other lumps or swellings? Family, Drug and Social History • Heberden’s and Bouchard’s nodes; Rheumatoid nodules • Family history: Ask about psoriasis, Previous arthritis • Sexual activity • Drug History: Ask about thiazide diuretics (if you wanna impress) • Disseminated gonococcal disease • Social History: Impact on life; Can they button their clothes, etc. • Sexually acquired reactive arthritis CONDITIONS THAT CAN CAUSE PAINFUL JOINTS Condition How would it present? Osteoarthritis Monoarthritis usually Elderly; Worse on movement and at the end of day Rest helps Rheumatoid arthritis Symmetrical polyarthropathy Small joints Early morning stiffness Gout Usually first MTP joint Isolated, hot swollen joint Typically described as coming on suddenly overnight (‘woke me up’) Psoriatric arthritis Associated skin plaques and nail changes Variable pattern of joint involvement Early morning stiffness Septic arthritis Isolated hot, red, swollen joint Very very very very painful Systemically unwellGENERAL TIPS • Apply SOCRATES where you can – you’d be surprised how much it can illicit • If you find yourself blanking, jump ahead – get as many points as you can • Your summary can be SHORT – you get a point for summarizing, not the length • Use the minute to plan what you want to ask and possible differentialsTHANK YOU! Please fill in our feedback form 2367445A@student.gla.ac.uk