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session before before I go and I, um Happy new Year to all my tubal friends out that, um, you guys have really good day enjoying it with friends and families on D. I hope you guys have a really, um, prosperous new year filled with them happiness. And, um, and the pills bit below the different blessings. And I hope you guys have a really good, really good day in the new year. But then the Vytorin, because cool. So we're going to go on Teo session today. So the endocrinology station So the main sort of topics for today's session is well covered. Important cases in endocrinology. Okay, in terms of examination cases, So cover acromegaly look of ah Cushing's syndrome on. We talked about thyroid examination in good detail today, Um, because that that's that that's a very commonly tested your core examination school. And so we'll make sure you guys are really confident in doing a thyroid examination. But we're going to start off talking through sort of, uh, other endocrinopathies as well. So we're gonna say it's sort of in terms of the different conditions. I'm gonna do a quick spot diagnosis to make sure you guys look familiar with some of the major aspects of these different end of nobody's. Just start with the first one. So we have a 46 year old man with type two diabetes mellitus, hypertension and obstructive sleep apnea. And he presents with weight gain and people joints. It's got no longer patent. When he flexes is rest for one minute, he starts to building. Uh, tingling and numbness in his fingers. Uh, what do you guys think? Yeah, so acromegaly cool. Um, why do you think it This is acromegaly one of the what is acromegaly at access? Er yes, acromegaly. So it's ah characterized by excessive levels of growth hormone on. But that's too much growth hormone. You're gonna get a whole lot of different complications. Okay, so this guy's got those different complications from having access and levels of growth hormone in the blood. Okay. Diabetes growth hormone increases sugar levels have attention. Obstructive sleep apnea. So again, complications of having too much growth hormone. Okay, weight gain again increase metabolism. Painful joints. Because of increased pressure because of increased size of tissues, gloves no longer fit him. So hands the extremities in general get bigger. Okay, Particularly hands and feet Just close. Don't fit him. What's this stuff about his vaccines? Risk for more minute. He's feeling paraseizures, but yeah, Couple of Thomas syndrome. What city? Sign Cold? Yeah, it's a steep hill and sign. Okay. Laxing is risk for one minute. Okay. And you feeling parasthesia? Yes. I could not sleep it Feel inside. We'll talk about feelings and Tinel's test in the skates. A shin. Okay. What? I'll talk through the examination, but, uh, this is one of the tests to check for a meeting. That median nerve compression couple tell us and don't typically cool. Next. 1 41 year old woman with rheumatoid arthritis presents with weight gain, 15 kg weight gain's 15 kg increase facial hair, acne, polyuria polydipsia, central obesity. And as a warning gait. I just again on the last one that remember you get the carpal tunnel in acromegaly because of compression off the because of enlarged soft tissues. Compressing the couples as over this scenario. What you guys think? Yeah, you guys, You guys know your stuff. So this is Ah, Cassie. Scenario off. Uh, pushing syndrome. Okay. What is Cushing's syndrome and excess off Which hormone is access in Cushing's? Yeah, cortisol. Forget it. Um, So what is the likely cause of Cushing's in this patient? What is the likely cause of the hyper cortisol Is, um yeah, I have to get it. Okay, so what s so that's the best that sentence is this patient has a history off rheumatoid arthritis tests. Okay. And remember, one of the mainstays of management and rheumatoid is things like corticosteroids. Okay. For the joint pain, we'll talk about rheumatoid arthritis. Management's in the MSG that issue as well, But there is commonly used very commonly used my patients with rheumatoid and so exhausting a steroid use for long periods of time is a very common cause off hypercortisolism. Okay. Cushing's syndrome on this patient has, uh, plastic features off high cortisol in the blood. Okay, weight gain. Increased facial hair. Okay, so just the woman woman with increased facial. I was thinking about her citizen acne as well. Okay. Steroid, steroid, acne. Polyuria polydipsia could be caused by access cortisol in the bud and Central beastie at, so you get fat fat redistribution in Cushing's syndrome. What about what is this water in gait? What is this suggesting? Yeah. Uh, proximal myopathy. Okay, we'll talk about It's hard to examine from proximal myopathy when we talk about the thyroid examination. But water engage her because of weakness and the proximal muscles there in order to maintain a normal gait cycle. They're having to what? I have a have a bottle in gait. Okay. Um, good next one. They're not your 1% weight loss. Intermitting palpitations, diarrhea, difficulty concentrating and trouble sleeping. JPs anxious and a skin is warm, patrician of both eyeballs. That scene she's a non tender and large thyroid with a bruit refax of brisket is a mild tremor on outstretched months. But I'm I'm trying to cover as many of the features. And how so you guys, when we actually cover them a bit more detail, you'll be a lot easier. Good. So we got all of hyperthyroidism, but we could be more specific. Let's be likely. Diagnosis? Yeah. Grave's disease get Okay, so this is likely, uh, patient with graves' disease. Okay, So disease, most common cause of hyperthyroidism. Okay, Um, this patient has many features off high thyroid. Her height, Arizonan. Okay, So increase the weight loss. Intermittent palpitations, diarrhea, difficulty concentrating. Trouble sleeping with insomnia. All classic features are hypothyroidism. Okay, Is anxious warm peripheries or features of hypothyroidism, The protrusion of both eyeballs. What is that quote except the arm? A sketch. Okay, so except Armas, also known as proptosis. Okay, they mean the same thing. Um is a important feature of graves' disease. Okay, It's specifically graves eye disease, which we'll talk about in detail, but except almost is a grade spastistic sign. Um, non tender and large thyroid. So graves disease. You can get a diffusely enlarged thyroid gland and you can get a bruit is well, so if you ask a day of the thyroid gland because of increased vascularity of the thyroid gland that you can hear a bruit, a brisk reflexes and mild tremor. Also, a chance again features off hyperthyroidism. Okay, Next one for sexual woman with weight gain decreases appetite and petite for several months. Three boats, irregular menses, constipation, always feeling cold facing eyes are puffy with loss of the lateral one done on my eyebrows. So reflexes. A slow paragard is in large history of celiac disease. But he has a You have good. So this is patient with over type of virus is, um's get. What do you think they're like because of the hypothyroidism is Yeah. Happy Motors. Okay, so that's the likely cause. They're so Hashimoto's thyroiditis very common cause off hypothyroidism. As someone said, technically, we shouldn't have any motors. It's a bit of an outdated. Um, Okay, technically, we should be calling it, um, chronic autoimmune thyroiditis. Okay. Or chronic lymphocytic colitis. Okay. But actually, Moto's it is still very commonly used in clinical practice. Okay. And we'll use it for me as well. But why is this hyperthyroidism to the special has loads of each show's up. Low diet home on weight gain, low appetite fatigue, irregular menstruation, constipation because of reduced motility on do, um, always feeling cold. Okay, So heat intolerance face and I start puffy with loss off the lateral wanted off eyebrows. So, again, this features off hypothyroidism. Okay. Puffy face, periorbital edema, loss of the lateral, one third of eyebrows. Important feature of hypothyroidism. Slow reflexes. Okay, generally stuff and hypothyroidism is opposite the hyperthyroidism. Okay, stuff speeds up in hyperthyroidism. Stuff is slowing down. And hypothyroidism. You got a large thyroid gland. Okay, Because the Carolinas trying to compensate so you can get a bit bigger. Usually will eventually atrophy. And the history of celiac disease is also in keeping with it being Hashimoto's. Because autoimmune diseases in general are associated with other autoimmune diseases. Okay, so after motors classically can be associated with things like celiac disease, type one diabetes, but a lot I go finish a senior. Okay, so that's just about diagnosis. Okay, We're gonna run through one of these conditions in good detail today. We're gonna start off with acromegaly, so we're in the GP. We've also we've been asked to see Mr Big, but a 43 year old male who has a history off acromegaly on would be nasty perform a focused acromegaly examination. So you're going to do some spot diagnosis, Okay, This is gonna be in very interactive. You guys gonna tell me the different science indicative of acromegaly? I don't. This one. What do you think, Frontal? Boston. Good again. You see this? Uh, the lack of hair on the forehead. Okay. Very prominent forehead as this is called frontal bossing. How about this one? What is that? Yeah, I look at the mouth, but what am I What's this concert here? Maxillary overgrowth? Yeah, basically. So it's macaroni natives. Um, so very prominent job. Basically. Okay. So again, because acromegaly you get very the size of tissues in general gets bigger. Okay. Particularly your, um a mandible. Okay. Um, so you get prominent job on that. That's known as a mechanic. And autism next one. What you think? Do you have, ah, patients? Um, driving license here. So this is very important. Okay. Always driving license. A very useful tool And acromegaly to compare what patients looked like previously. Okay, many years ago and what they looked like now to help you compare any changes in things like facial features. Yeah, course spatial. Which is very good. Okay. Course faces again. If you really can't look a difference based on a lot more course, the gate. That's bet again. Classical acromegaly. Uh, what about this one? Here, look. A teeth, Look it up by Compare the bottom teeth to the top teeth, the mandible teeth, patio maxillary teeth. Yeah, Why? Why? I'd space teeth. Okay, so you see the space here between the teeth and the bottom, the mandible bone is a lot greater. Okay, It's much more widely spaced apart. And this is known as a diastema. Okay, there's increased I steamer between the tea from the bottom. Remember, acromegaly there is usually that the mandible increased in size a lot more prominently compared to your maxillary bumps. Okay, so you can see the the top teeth on about much affected, but the bottom teeth are affected. Cool. Uh, what I think about this guy's hands? Well, yeah. So Yeah, the same you said. So these are spent eight, like, hands. Very good. Okay, this is what they're If you guys ever seen a speed, Okay. But you know what Of space it looks like, Uh, this is what that this is Looks very similar to it. Okay, there's the hand in general is increased in size, and it looks like a spade. Okay, we're on acromegaly. The extremities get very large. Okay? Particularly the hands. And so these are speed like hunts. Uh, next one. What do you think for the patient's tongue here? Yeah, Macroglossia. Very good as a huge time. Okay, again, acromegaly. Things are just getting bigger, Okay? Such a soft tissue, such as the tongue. Uh, next one. This is this is a This is very similar. Today is It's basically the same as same concept that the speed like What do you think? What? I'm going to get up here. Yeah, the ring doesn't bit. Okay. So tight. Wedding ring. Okay, this is it. Still, this is still counting as a physical finding. Okay, It's still it. Basically, in keeping because of the space like hands, you want to look generally when you're doing examination for patients who have things like acromegaly. You want to try and find ways off being able to compare how that body has changed. Okay, so you look at things like your driving license here. Compare how that facial features of changed things. Like a wedding ring suddenly bit a lot tighter than usual, or someone's belt size has changed. Okay. Or someone's like general clothes are fitting as they as they used to be. Okay, so this is trying to get it. Like you want to look at some of these Not necessarily on the patient, but just thinking about it. More laterally. Okay. About how patients lifestyle. It might have changed because of that condition and noticing things like a wedding ring which is where they would be wearing for a couple of years. Probably again that they haven't noticed that become tight fitting. Um, that's just stuff to pick up on it. Last one, this is Ah, is the mean. But, uh, what do you guys think? I've had a guy that we have. Morgan Freeman. What do you think? I'm trying to get out with the, um, voice in acromegaly. Yeah. Deeper voice. Okay, so I don't think so. In acromegaly patients because of enlargement, soft tissues around it firings. That voice gets a lot deeper. A lot. Husky. Okay, so try to get you know, Morgan Freeman's on a very deep, very famous voice. Okay? Famously deep post. So that's another important feature off acromegaly because there's some just general pictures off achromatic jungle. Physical findings. Okay, again, it's all about the increased size of our soft tissues. Cool. So can you tell me what is the classic visual field defect you get with a criminal? Yeah. Bitemporal hemianopia can you can use, um what is acromegaly usually caused by? What's the most common cause of acromegaly? Yeah, it's usually due to a pituitary adenoma. Okay, so it's usually due to pituitary adenoma producing and access Homer like excess growth hormone. So, again, as you said, the most common visual field defect is visual as a bitemporal hemianopia. So we're gonna go through visual field defects quickly. A Z guys said so. Typically, acromegaly is due to an enlarged pituitary gland, so you can see the pituitary. Here we have the optic nerve, the optic chiasm here when you have a pituitary adenoma can enlarge and compressing the optic chiasm. And you could get visual field defect know nice a bitemporal hemianopia. So at this diagram of the visual profit, okay, if you got shooting to our endocrinology from finals, you'll be very familiar with this stuff. But I would just, uh, again with this diagram. Um, but if you haven't made sure to check out that the recording of that session, which is currently available medal. But again, this is a visual field halfway So with a, um, Januvia, it can typically even in largest such as an acromegaly, can compress at this level here, which is the optic chiasm where the optic nerves cross each other. Onda, um, because of the fibers that are crossing out the optic chiasm you can get a bitemporal hemianopia. Okay, so again, because at the optic chiasm you're losing the fiber is coming from the nasal hemiretina in both eyes. You're losing the temporal visual fields. Okay, Your lateral visual feels Assad. See, classic visual field defect you get with a large pituitary gland. Okay, Again because of mass effects, compressing the optic irs. And typically, you get a bite and pull him, you know, be a so as we did during the endocrinology final session, we're going to do something quick. Visual fields defects, revision. So I'm going to draw on some visual field defects on this diagram, and you guys are gonna tell me, uh, the visual field defect, okay? And I want when you are describing the visual field defect when you guys to be as specific as possible. So that's not off with defect here. What type of visual field defect has got that going to produce? You need laughter, Blindness. Can you be more specific or technical injection? Yeah, it's Ah, right. So you call that right? Monocular vision loss. Okay. S o. There's a complete lesion to the right optic nerve. So all the fiber is coming from visual information coming up from the right right now is gonna be lost to get it right in ocular vision loss. Okay. Complete loss of vision in the right eye. Uh, cool. Ah, what if someone has a defect like this? So there's a defect. Compare compressing laterally at the optic chiasm you're losing. Your, um, visual field is coming from your temporal retina heavy right now in both eyes. Yes. So you get a buy nasal him, you know, be a Okay, so it's literally reversal off a bite and problem, you know, basically losing your lateral having right now in both eye. So you're losing your nasal visual fields. Are you getting by nasal him? You know, be a, uh, Let's go here. What do you think about if it patient has defects as a lesion affecting be right optic tract. What type of visual field defects are you going to get? Yeah, So you get a left homonymous, um, you know, be a Okay. So you lose the entirety off your left visual fields in both eyes. Okay. Uh, do you get macular sparing with it if you have a lesion? Here is the macallister bad? No. Okay, so there's no microsphere again. So, typically, when you have a lesion to the to the optic tract, you get a contralateral homonymous him. You know, be a without Marcus bearing. Okay, What was the classic cause of a, uh, optic track? Ah, he's in working that damage and 60 optic track there a stroke specifically. What type of stroke? Yeah, See, a stroke. It's okay. So typically am see a stroking lead to a contralateral. Help. Um, on, um, a stem, you know. Okay. Okay. These don't, uh, bit tricky. So what would happen if the patient has a lesion? Yeah. So, lesion to you. The lower bundle off the right optic radiation. What type of visual field defect it is. It is it. Is this a bit trickier? Yeah. You guys got it. So you get a left homonymous superior quadrantanopia. Okay, so when you have lesions affecting the optic radiation, you get a quadrantanopia. Okay, so it's only a quarter inch off the visual field. It's infected on. So when a lesion to the lower bundle of the optic Brady a shin because it's carrying information from the lower right now, you'd lose the upper quadrants. Okay. And again because it's the right side that you get a contralateral homonymous seven. Okay, so again, it's a You had a left homonymous superior quadrants, no beer. So basically, the the superior fields off the both eyes, but specifically the upper left quadrants. Okay? And it'll be the vice versa for the upper bundle. Okay, so if you have a lesion up a bundle off the off the Grady a shin, you get a, um, inferior quadrantanopia. So you lose the inferior quadrants and again because it's the lesion effecting the right side of the pathway. You get a left homonymous inferior quadrant. Okay, So the key thing if someone has a parietal lobe lesion that will lead to an inferior quadrantanopia. Okay, If someone has a temporal lobe lesion, I'll lead to a superior quadrantanopia. Okay, As of someone has different types of strokes or different concepts that affect these different locations, you get different quadrants. No pus. Okay, Good. Last one. What if someone has a lesion to the right? I'm very visual cortex. Yeah. So you get a So it's similar to the lesion to the right optic tract. Okay. You got a left homonymous Hemianopia. Okay, so you lose your left. Both feel after your fields in both eyes, but you get classically, you'll get matter of sparing. Okay with a with a lesion. Effectively. Primary vehicle. Cortex of the central vision is typically I'm not affected. Okay, so, classically, you get it with the PC a stroke? Because which gonna back the Rituxan cause a, uh, lesion up to the primary school cortex. But again, you get a contralateral homonymous. Um, you know, be a but with Markus bearing Okay, good. I hope that was useful. So just a quick visual field defects. Revision. Okay. Again, in terms of the endocrinology, remember, with toujeo no more classically, you'll get a bitemporal hemianopia. Make sure you know you're different visual fields, new packs. Okay, cool. So back to our endocrinology stuff. So talk about acromegaly. So in terms of the investigation, So in terms of diagnosing acromegaly, remember, the first step is not to measure the growth hormone levels. Okay? It's not even though acromegaly is characterized by high levels of growth hormone in the blood. The key thing is that the first step is to measure the I Jeff one. Okay, the insulin like growth factor one. So I get one is a hormone that's produced as a result of group from, um so again watch our endocrinology from final session to review the physiology. But growth hormone will stimulate the production of Jeff one from the liver. So when growth hormone increases, I get phone will also increase. And you guys tell me, why do we prefer to use idea if one compared to grow comma? What's the benefit advantages of using idea? One compared to growth hormone levels to diagnose acromegaly? Yeah, it's less. It's much more stable. Okay, it's produced from the liver. It doesn't have a postal secretion by growth hormone. That's like a growth hormones level of the Berries very much throughout the day. And also growth hormone it It is a stress hormone. Okay, so in situations are, uh, physiological stress, growth hormone levels can be elevated. Okay, but I just want it's levels a lot more stable. Okay, so that's why we go for the IVF one as a sort of screening tool for acromegaly. And then So if the idea phone is normal, that basically rules that acromegaly if it's unequivocal. Okay, so we can't definitively rule in or rule out the disease. Then we could do an old glucose tolerance test. Okay. And so remember, growth hormone levels will increase glucose levels. So if you or a glucose tolerance test and the glucose is not suppressed, that indicates that they have high levels of growth hormone in the blood. Okay, that will confirm the diagnosis. Okay. Um, so, eh, So if you died in once, you've confirmed the acromegaly. Remember, the most common cause is a pituitary adenoma. So you want to do a scan? So MRI of the pituitary gland and I will hopefully help confirm the pituitary adenoma. Okay. Um, so again, first step idea if one If that confirms that, do an MRI. If it's unequivocal, you can do an o d t t good. If the MRI is normal. Okay, If you're not able to visualize the adenoma on MRI scan, there's other investigations. More special stuff you can do, um, in terms of your skis. Is there any other investigations you would tell the examining you do okay outside of these sort of diagnostic investigations, what else might be useful to mention to the examiner in a Noski. Yeah. So other Children hormones? Definitely. Because pituitary adenomas. You wanna, um generally just check of any other pituitary hormone is in a deficit or in excess. Uh, compared to old pictures. Yeah, that's definitely a good thing to mention. Okay, Definitely. I I don't That's happening. Would be a difficult thing to tell the Examiner. Cool. So again, in terms of our ski investigations, have spit it up into your bedside bloods imaging of special tests. Okay, so I said, you gonna say you get observations, check glucose levels. Okay, for because you get you get the high levels of glucose from acromegaly doing the CD because acromegaly can affect the heart in different ways. Okay, Visual fields assessment. Okay. Bitemporal hemianopia. Classically with jargon oma. There's a blood test. So as better flow judges are idea four levels the toujeo hormone screen as you guys set. Okay, check if there's any hormones and access of deficit and in terms of our imaging special test. So we mentioned that the MRI pituitary gland is the key investigation. Teo, localize the pituitary adenoma. Cool. So go by the type question for you guys. Can you tell me one of the complications off acromegaly. Yeah, it's totally some different complications of acromegaly at the you can mention colorectal cancer, good heart failure, carpal tunnel syndrome, good hypertension, diabetes, obstructive sleep apnea. Okay. Caught him up with the hypopituitarism goods. Yeah, you can, um, acne. So generally you're getting these complications because of organomegaly. Okay, Because of different organs getting bigger and compressing tissues or producing too much stuff or just failing. Okay, I'm very useful. Nouman it If you if you're ah, you Monix kind of guy. Uh, the you can use this off about pneumonic to remember some of the different complications. So we got a for a contest is not guns. Be for high BP. Okay. See, for carpal tunnel syndrome. Okay. We talked about it. Be for diabetes mellitus. Okay. You got high glucose levels before enlarged organs. Okay, so organomegaly for field defects. Okay, so we talked about it. The bitemporal hemianopia g four g i milligrams. See. Okay, so you guys talk about colorectal cancer, you've got a goiter is Well, okay, um hate for heart failure. Her citizen, um hypopituitarism I for increased. I Jeff one. Okay, so we're just making up the new monitor there J for joint pain. Okay, so our property very, very common in acromegaly because of be organomegaly kyphosis as well. Okay. Absolutely. Spinal deformity l for lactation. So remember acromegaly typically do too. Because to treat adenoma on prolactin is very commonly affected. Okay, productive. Release on. So you can get Galleria because of it. Em for my oxy. Okay, so acromegaly is in the differentials for proximal myopathy hands. That's an important, um So, um, isn't that against in the difference of proximal out the amongst other things which we'll talk about? Okay. We'll talk about how to examine for approximately up. Delayed, drawn. Yeah. So that's it. Um, with It's a sort of short case for acromegaly gave us. We talked about these electrical features, investigations and some complications. Um okay, Same. What's the definitive management for acromegaly? What's the definitive management step? Usually for acromegaly? Uh huh. Yes. So if you had asked about it, it's ah transferred over resection. Okay, that's typically first line for acromegaly. It's remember, we don't go for medical therapy first and acromegaly we go straight for surgery and acromegaly okay, because of the high risk of complications are you get them, Get the get the adenoma removed as quickly as possible. Which is different to Prolactinoma is where we go from. Medical therapy first. Yeah, but acromegaly First time management is search for resection. Um, cool. So let's move on from acromegaly. Now let's go on to talk about Cushing's syndrome again. We're gonna go through in a similar way, but we're going to start off with some spot diagnosis because there's a whole bunch of different causes of Cushing's syndrome. Okay, and the investigations can be very very. People find it very difficult to understand the investigations for Cushing's syndrome. So we're gonna test how much you already know about investigating Cushing's and the different clothes of Cushing's by doing a quick sport diagnosis session. So we have a 44 year old man who presents with a Christian going to have a test on on on examination. He has a visual field defect. Morning ACTH is high. What do you think? Yeah, so, um, you guys, Cushing's disease get okay, so And what is Cushing's disease? What's the Was the lesion in a Cushing's disease? Yeah, So Cushing's disease is a problem in the pituitary gland. Okay, So Cushing's disease means that it is an ACTH producing at a tumor in the pituitary gland. Okay. And that's eating to pushing syndrome. Okay, So why is this? Why is it cushions? Disease test. So? So it's quite confusing. So Cushing's disease again, it's means that the problems in the pituitary gland Okay, so Cushing's disease has cushion. Would habitus. Okay, uh, on examination has a visual field defect. Okay, so we're trying to get up the again. We talked about it. It enlarge for two trees and cause a defective visual cough way. Morning. ACTH is high. Okay? Key thing with Cushing's disease is that it is and ACTH dependent cause of Cushing's. Okay, So that means that the high levels off course, all in the blood is dependent upon that being high levels of a stage. Okay, So, again, cushing's disease disease, it's a A CT. It's producing, uh, tumor. Okay, so you're gonna get a high morning ACTH. Okay. Uh, cool, eh? So so that's what's the difference between Cushing's syndrome and Christians disease? Cushing's syndrome. It's just the syndrome literally just means high levels. Of course. All in the blood okay, just means hypercortisolism but there's lots of different causes for high loves a cortisol in the blood. Okay, if you say someone has cushings disease, you're saying that the high levels, of course, all in the blood is because off the pituitary gland, producing too much ACTH, okay? And that ACTH is causing the adrenal gland to produce a too much cortisol. Okay. And that's what that's a different story. I got to take call a minute. Dana. Nine election. Londoner, I buy medicine. I'm sorry. It's on. So we did the question of disease. Next one we have a 55 year old woman presents with a cushion would happen. Tests. She has a history of chronic disease. Low dose dexamethasone failed to suppress cortisone. Uh, what you guys think? Yeah. So exogenous says steroid use cuts. Okay, so this is similar to the first spot diagnosis thing we did about okay about the rheumatoid. So if patients take steroids excessively, that can cause Cushing's as well. Okay. So exhausted excess exulted the sex or do so okay. The history of crone's disease suggests approach diseases. Another condition, classically manage with the steroids regularly. Okay? Steroids are important aspect of inducing remission. and Crone's disease patients low dose dexamethasone. So we'll talk about investigations. But the low dose Dex medicine suppression test is test to confirm if someone has high loves of quarters on the blood. So because low dose dexamethasone failed suppress Colazal. That indicates patient has high levels of cortisone in the blood. Because of the history of crone's disease that indicates that the high levels of cortisone is because of exogenous steroids. Next one, as we have a 70 year old man who presents with a cushion, would happen to us. High dose Dex. Medicine does not suppress cortisol. Has a long smoking history. Yeah. So this is a small cell lung cancer. Okay. Um, so how does the small cell lung cancer cause, um, Cushing's syndrome. Okay. Yes. Oh, ectopic ACTH production. Okay, it's it's known as a paraneoplastic syndrome. So, um, so, uh, apparently, a plastic syndrome means a tumor producing different types of hormones. Okay, So small cell lung cancers, it can produce loads of different hormones. Okay, One of the types of hormones you can produce, ectopic lee is ACTH. Okay. And again, the ACTH can, as just similar to the Cushing's disease, the ACTH can stimulate the adrenals to produce loads of quarters of a pack. And that can cause Cushing's, um so the key investigation, too. So again, as I said so cushions, disease and small cell lung cancer, they both causing high levels of ACTH, which will cause high levels of cortisol production. Okay, but the way you conduct Enshi eight between Cushing's disease and small cell lung cancer is to do the high dose dexamethasone suppression test. Because what? Cushing's disease, the cortisol, will be partially suppressed. Okay, After doing a high dose dexamethasone with a small cell lung cancer, it won't be suppressed. Okay, so that's how you can differentiate between Cushing's disease and small cell lung cancer is by doing the high dose dexamethasone suppression test. Okay, last one six year old man presents for the question would happen. Tests. There's no history of long term steroid use, but But his morning east, each level is low. What do you think? Yeah, adrenal eso. Adrenal lesion. Okay. You don't necessarily know if it's a tumor. Okay, But typically, typically, usually it is a tumor. Okay, So some something wrong with the adrenal glands that's causing the adrenals to produce too much cortisol. Okay, so think about it. Okay, so the adrenal glands are hyper secretion. Cortisone. That's gonna cause negative feedback. Okay. And that will cause the ACTH to be low. Okay, so it's different to the other causes. Okay, So Christians disease and small cell lung cancer. The east It was high within adrenal lesion. The ACTH will be low. Okay, the morning ACTH will be low. Okay. And again because there's no history of long term steroid do. So we've ruled out exogenous steroids, so I trajenta causes off Cushing's syndrome. So it probably means the patient has something wrong with his adrenal glands. Okay, cool. So let's talk about some physical findings for Cushing's syndrome. As we talked about different causes, we're gonna cover some physical findings. What do you think about this patient? Yeah, Moon face is good. Okay. Okay. So quick. Dip it and you're all ski. I would try and avoid saying moon face. Okay, this is this is a skill in itself, okay? Being a talking in front of patients, I just think if you're going to say that the patient is moon faced, other thing is that it sounds that good okay. Especially if the patient doesn't actually have Cushing's syndrome, and you call them moon Face. It's going to reflect that well on you, because I try. I try and use Ah, bit more. Quite language. Okay? I just said cushingoid basis. You guys, the right move, move faces is how you can describe them. Base appearance here. What about this one here? Yeah, into scapula back product. That's a good way to describe, actually. So this is a buffalo hump. Okay, so, um, buffalo hump. So there's fat redistribution to the upper back. Okay, again, Cushing's syndrome. You get fat redistribution, and you get this classic buffalo hump as well. Uh, what about this one? This is a very subtle sign. Okay, this is Ah, subtle sign. What do you think? What do you think? The examination finding here. If you guys do What if you guys do on your on your own fingers what the exact would be physicians doing and try and compare the difference? Not pale skin. Yeah, Skin thinning. Very good. Okay, thin skin. Okay. So you see what? What do you positions doing here is over the sort of blocks more balance of the fingers rolling their skin over the joints. Okay. And if you guys roll your skin over your own joints, Okay, hopefully you'll see that it's quite thick. Okay, The amount of skin you can roll over it's okay to quickly more than two millimeters of skin. You can roll over there joints. But here the patient has been skin because of Cushing's syndrome. Onda. Um, so there's not much, actually skin being rolled over because this thin skin Okay, so that's a physical finding off. Skin thinning, caustic for Cushing's syndrome. Okay, BU get general skin thinning. Ah, cool. Next one. I already I think. But this dermatologist future. Yeah, I get acne. Okay, so this is steroid acne. Okay, So remember, common cause of Cushing's is exhausting a steroid use. So you want to look out for features? Signs off steroid use. Okay. There's many different signs of steroid use. Okay? One of them is things like acne. And classically, the acne you get with steroid use is typically most commonly affects the chest. Okay, Although, although you can get it over the face and other locations while but classically but very commonly, you get it over the chest area. Uh, next one. What do you think's happening with the skin here? And I'm not trying to cry during it. They're they're destroying. Okay, What else? What else can you say Central adiposity gets, Um What about What's this? Describe bruising. Good. Okay. Easily bruisable skin, like as the main thing. I was trying to get up. Okay, They're easily Bruce foreskin again. We're pushing syndrome yet Thin skin, very easily. Bruisable skin. Okay, because of the hyper course, all is, um, again features to look out for. And we'll see. This is a weird location to get bruising. Okay, So you can You should be thinking if someone has some kind of condition that's leading to easily bruising, um, think of things like Cushing's syndrome. Okay, because it's not like in areas where you're gonna fall typically like, um, so I think always try and think laterally. What about this one? So this is what you guys were describing? Yes. Trying to get okay. So doesn't see you see these abdominal strike a here. Um, how can you differentiate the straw you see in Cushing's syndrome to destroy a you see in obesity? Is there a difference? What's the difference. Yeah, the color of the fret. Yeah. So, in obesity, it looks a lot older. Okay, Destroy there a lot there. A lot. Generally. A lot sooner. Okay, the stronger you get an obesity on destroying here that are very thick. Okay, much more violations. Look, about for purple. Okay. So again, destroy a is the straw. You're getting obesity and start you getting Cushing's. This is a typical pattern. Australia. You can get in Cushing's syndrome. Ah. What? What What is this, a physical binding here? Yeah. Ah, this is so this is basically male pattern facial growth. Okay. And a woman s So this is, um, her statism. Okay, this is what her system is. A histamine. That hurts it. It is, um, is the last one again? This is not This is just important to pick up at the on the patient if the patient's wearing it. Yeah. So I've combined them both here, but there's a startle it. Okay. Different ways of showing that a patient on Starlix. Okay, so we have a steroid. A little bracelet here. Patients can have a seven alert card. Okay. They put it in their wallet. Important things to pick up on. Okay, again, We talked about with diabetes. Okay? So patients can Web, different types of they can wear medical evident I d bracelets for different conditions. Okay, It's just important to be aware if it's okay. Have a look. Why they Are they wearing this bracelets? Okay, uh, why is it important that patients have a steroid, a little bracelet or steri card? Okay. Why is it particularly important with storage that they are able to be easily identified by health? Professional? Yeah. Good. Okay, so, um, patient patients are on long term store. It's okay. And they become unwell. Um, they need to be able to communicate your health, professional someone that's their own. How long term stories? Because there there's a risk of them being in an Addisonion crisis. Okay, so they become somebody unwell. They haven't been taking that normal dose of steroids, for example. That could potentially lead to a and it's only in crisis where the adrenal glands just shut down. What? Your drink could be access, shutdowns and pictures. Could get very unwell with it. Okay, so it helps. Someone can recognize that they have this alert bracelet. They can immediately. Oh, is this patient economy in an actor soon in crisis. Does this patient need some kind of started replacement? Okay, so that again just important to be able to pick up on these different features. Uh, good. So let's talk about the, uh that's about some question about Christian syndrome. So even examiner, just ask you just point blank. What is Cushing's syndrome? How would you How would you reply? What would you sort of sentence be to just describe what is Cushing syndrome? Yeah. So, Cushing. So you could say Cushing's syndrome is a condition characterized by high levels of cortisol in the blood. Okay. And so, in terms of the cause of Cushing's syndrome again, if the Examiner asked you, can you tell me what's a good way to classify? The cause is of Christian syndrome. How would you classify the cause is of Cushing's syndrome. Yeah. Okay, so, um and also he is always about being able to structure. Your answer is okay. So in terms of the cause of Christian syndrome, you can divide it into your ACTH independent causes and your ACTH dependent causes. Okay, So a speech independent causes means that you're getting high levels of cortisol in the blood independent of there being high ACTH. Okay, but with a c h dependent Cushing's it means that the high levels of cortisol in the bud is dependent upon that being high levels off ACTH. Okay, so with the ACTH dependent cause of Cushing's ACTH is gonna be high. Okay, But in a ch independent course of Cushing's ACTH will be low. Okay, surgeons of a stage independent causes. We talked to 22 of the maintenance I I found this new Monica called cause. Okay, so see, for cancer. So adrenal cancer A for adrenal hyperplasia. Okay. Awful rad causes such as this Ah, very ragged condition called McCuen All bright sun room. And ask the steroids, which is a very common cause of a stage independent Cushing's. Okay, so remember the major causes steroids and adrenal lesion. So okay, those the two most common causes off an East independent Cushing's and in terms of a state dependent cushions. So there's two main ones. Okay, which we talked about One is the pituitary problem. Okay, so if there's a pituitary gun producing too much ACTH on that's called Cushing's disease okay, on again. That's a state dependent. Cushing's and the other common cause off ACTH dependent Cushing's is if someone has some kind of situation off act topic Easter egg secretion. Okay, so a CH produced from places outside of the pituitary gland. Okay. And the most common cause of that is small cell lung cancer. Okay, so it tells the counter peaches off Cushing's syndrome. It's a multi system disease. Okay, there's various different symptoms off Cushing's syndrome. So high loves a cortisol. It's going to affect the metabolism, and it'll burn through different tissues like the skin, the bone. Okay, and as the effects on the E on psychiatric symptoms, actual symptoms and those two different complications as well. Okay, so very important. Teo again, just be able to classify these different beaches, okay, according to the different specialties. But again, it's all because of the high loves of quarters all it's a multi system disease. Okay, we're gonna spend some time on investigating Cushing's syndrome, okay, because I want to make sure everyone is very, very crystal clear on the different investigation steps for Cushing's syndrome. So the way I like to teach the investigation for Cushing's syndrome is to talk about it in three major steps. Okay, so the first step investigation could Cushing's syndrome is to exclude steroid use. Okay, because that's the easiest way. That's the easiest cause of Christians to rule out. Okay, you can just check their medical drug history check of their features off access, steroid use. Okay, cause that's gonna easily help you determine what That what the cause of Cushing's is, once we've excluded it, then you want to confirm if they have high levels of Colazal in the blood, okay? And there's three main ways you can confirm if they have hypercoagulable. Um, okay, how? I love the quarters on the blood. So the one way is to do the 24 hour urine, every cortisol level. Okay, So basically, collect urine samples throughout the day and check and test the cortisol levels. The other way is to do the midnight cortisol levels. Okay, So, midnight salivary cortisol levels on again tested. That's high. And the other ways to do a low dose Dex minutes and suppression test. Okay, So low dose. Expect suppression test or dexamethasone, basically a synthetic form of cortisol. So if someone had normal cortisol levels in the blood. If you do a low dose, Dex, months of suppression test, you'd expect cortisol to full. You'd expect to do be suppressed. Okay. If someone just had normal hours, of course. All in the blood. If you give a low dose, Dex met seven. You should expect the cortisol level to be suppressed. Okay, but if someone has hyper quarters, all is, um okay, it won't be suppressed by a low dose Dex medicine suppression test. Okay, so, again, colon three tests are ways of confirming. If someone has high levels, of course, is all in the blood. Okay, um, and it was in terms of the low dose, so it's typically used 1 mg of x medicine. Okay, that's the classic. Those for low dose dex matter. Um, and again for the midnight cortisol levels were typically testing these saliva. Can you tell me why do we test the saliva instead of blood? What's the point? Was pointed. Doing the saliva records are levels. Yeah. So if you think you think about your medical students coming along and coming along in the ward coming along to take some bloods, patients can get a bit stressed. Okay, that can boost stuff that quarters all in the blood, so that can affect the bleeding. So we typically takes alive records are levels. Okay, um, you want me to repeat? Repeat the low dose again. Low dose, Dex. Much suppression tests. If someone has hyper cortisol is, um, the course of your levels won't be, um, suppress after doing a low dose dexamethasone suppression test. Okay, um, if someone had normal cause our levels, it will be suppressed after a low dose. Experts on suppression test. Okay, so that's up to you. Okay. So confirm that they have high levels, Of course, all in the blood. And once you've done that, once you've confirmed that have high levels of cortisone in the blood. Then we want to know where is the court is all coming from. Okay, we're going to know. Is it a a C t h dependent cause of Cushing's? Or is it an ACTH dose dependent cause of Cushing's? And as mentioned, if someone has a c t. H independent cause of Cushing's? Because I don't mean that the state would be low, Okay, the morning a stage would be low if they have a a stage independent course of Cushing's because and because of negative feedback. So, for example, if the adrenal gland is producing loads of cortisol, that's gonna feedback negatively on the toujeo land. And I will cause low ACTH. Okay, so low. So examine you confirmed High loves the cortisol low morning sth. That's an East huge independent cause of Cushing's. If someone has high levels of the stage or on inappropriately normal level of a CH okay, then we can say that it's likely an ACTH bill pedicles of Cushing's. Okay, so the high loves of cortisol is happening because of high levels off ACTH. And again, as we said, there's two main causes. Okay, there's a pituitary problem, and there's an ectopic problem. Okay, if someone has a a state dependent cause of Cushing's, the way we can differentiate it is by doing the high dose dexamethasone suppression test. So high dose. Typically it's 4 mg of Dex Dex matter. So when you get hypo Staxyn, it's, um, if someone has a pituitary source of cortisol of ACTH. Um, if you do a high dose expensive suppression test, the cortisol should be at least partially suppressed. After doing a high dose dexamethasone suppression test if they have a pituitary problem. But if they have an ectopic source of ACTH, Okay. For example, if the small cell lung cancer, the cortisol will not be surprised. Okay. So, again, if the cortisol is is suppressing your partially suppressed after doing a high dose dexamethasone suppression test, that indication patient has cushings disease. It's not suppressed. It indicates that they have an ectopic source of east huge. Okay, so hopefully that's clear. So that's how we can. That's the sort of diagnostic pathway. Okay, um, in terms of your off skis, so make sure you're very familiar with how you die. Nose, um, Cushing's syndrome. Okay. But in terms of all see, sort of presentation of investigations, uh, again, do your bedside blood imaging special tests. That's an investigation. You can mention your observations, people, those levels, because your soul can increase your glucose levels, you're in debt. Okay, because you know, technically goes again, um, blood tests. We talk about all these different blood tests you want to do. Okay. Full blood counts can use one Cushing's to look for leukocytosis. Okay. Increased white cells. Uh, why would we do you in East. What could you? And he's tell you in Cushing's syndrome, what type of abnormality might be seen in Cushing's syndrome? On your knees? Yeah, very good. Okay. So you can get electrolyte disturbances. Okay? Particularly hypokalemia. Okay, I get because you could get hypokalemia because the cortisol can, um, sort of act like mineralocorticoid and increase potassium excretion. Um, lipid profile. Again. You're getting problems with lipid distribution. Uh, ABG? Why would really doing what would it be? Over? Couldn't ABG show you and Cushing's syndrome Very good. You guys are on it. So metabolic alkalosis. Okay, so metabolic alkalosis is another feature of Cushing's syndrome. So again, you it needs It's the same concept as the hypokalemia. So if you have high levels of cortisol levels Okay, uh, that cortisol can acts like a mineralocorticoid on increase excretion of hydrogen ion. It's okay, which can lead to a metabolic alkalosis. Okay, so, again, because it's acting like a mineralocorticoid, we can increase potassium expression. If you need too hyper cleaner, it can increase hydrogen ion expression. Which meter? Metabolic. Our closest. And also, technically, it could potentially increase sodium retention, which can lead to hyponatremia gave not that common typically, but yeah, that's those are different blood tests and why we do them. And some imaging a special test. So, depending on where the lesion is, you can talk about what your first line against. If it's an adrenal problem. Typically, CT adrenals as first line Cushing's disease. So if you have a pituitary source MRI to pituitary gland. Okay, um, most most lung cancer, chest X ray, ct chest, uh, dexa scan. I also said, because, uh, the risk of osteo process with pushing syndrome. So I love the cortisol level. Okay? I love the quarter. So can basically melt the bones. Okay, you get risk of, um, what's your process with Cushing's syndrome quickly in terms of Cushing's disease, if the MRI head is negative. What? What what other investigation might could you do if someone has an If you think someone has a Cushing's disease and used but that MRI head doesn't show that they haven't adenoma what else is going to do? Yeah. Yeah, very good. Inferior petrosal being a sampling s o. So if you think so again, Cushing's disease problem in the pituitary gland. If you do an MRI heads and you're not able to visualize the adenoma, But you still think that they have questions Disease? You can do inferior petrosal being a sampling. So the pituitary gland if you guys know it's drained by inferior petrosal veins so you can do petroselinum sampling most of the level of east teach, uh, coming from the pituitary gland and compare it to the ACTH in the blood. Okay. And you can compare if it's significantly higher and considered a gland compared to the blood. Okay. And that can help you confirm the diagnosis off, uh, Cushing's disease. Okay. But again, you only do that if they're MRI head. MRI is not able to show the lesion, and you suspect that they have, uh, questions. Disease. Okay. Cool. Um, okay. I've got a quick activity for you guys. So this is basically, hopefully just testing. You guys properly understood the investigation, so I want you guys to fill in the rest of the stable with either an upper Oh, a downer. Oh, okay. Tell me if it's increased. Decreased. So it's Cushing's disease after a load. Those tax medicine suppression test is the morning cortisol level going to be high or low, but Cushing's disease. Yeah, it's gonna be high. Okay. And with small cell lung cancer, is it gonna be high or low the morning cortisol level? Yeah, it's gonna be high. Okay, so remember all three tests they're telling you basically the second okay, That all three of these tests that just diagnosing someone with Cushing's syndrome. Okay, so if someone has high levels of cortisone on blood, all of these tests, because I will be, will be high in all of these different tests. Okay, uh, for small cell lung cancer, is the ACTH high or low? Yeah, it's high. Okay, so remember, small cell lung cancer is an ACTH dependent cause of pushing. So a stage will be high with adrenal hypo secretion. So if someone has an adrenal lesion, is it gonna be alone? Yeah, it's gonna be low. Okay, so it's a ch independent cause of Cushing's. Okay, So you get next to be back, which woke reduce the morning. Sth okay. On. Finally, to differentiate Cushing's disease and small cell lung cancer with the high dose expresses medicine suppression test the morning cortisol. Is it going to be high or low with Cushing's disease? Yeah, it's gonna be low, okay? It's gonna be suppressed. That's that's what we mean by Donora. Okay? The morning cause it will be suppressed, but he's partially suppressed after high dose. That's not some Cushing's disease. Okay, cool on. Quickly. In terms of I just don't like quickly. Someone asked you management of Cushing's disease, you can again split it up into conservative medical and surgical management. Okay, um, we're not going to go through this, but quickly. Just remember, always in terms of conservative management. Talk about the MBT approach. Okay, so, gp and a crime uric. Surgeons assessing manage comorbidity. So Cushing's syndrome, There's a whole lot of different co morbidities patients might have. Okay, you talk about charities, okay. Like to treat foundation until they have the vaccination status updates. Okay, because patients were pushing syndrome, in particular the immunosuppressive. Make sure that they're vaccination. Status is up to date. Okay, my score complications. A medical management you could give spironolactone to manage hypokalemia. Okay, so it's gonna block the basically blocks the effects of cortisol on the kidneys. Um, after they've had surgery. Okay, So remember, definitive management is to remove the adenoma with surgery, but after the surgery. Typically, patients need to have some glucocorticoids replacement. Okay, just to supplements post surgery. Remember the general advice of patients. Describe steroids long term. Okay. They need to be wearing an alert bracelet, okay? Or have a A i D card. And they if they get ill, okay, They have any interferon illness. They need to be aware that they generally need to double dose. Okay, They don't stop taking steroid. Usually need to double dose, double dose if they're taking and steroids. Okay on because of the risk of for Addisonion crisis, let's have a break. Okay, so we cook through acromegaly and Cushing's syndrome. Okay? We're gonna talk about thyroid examination after the break. Okay, so let's take a five minute break. I will come back at 8. 13. Eso talk True's would cover the carotid is tired examination and good eater. Okay, But first, I want to make sure we got some basic concepts in our disease. Kneel down. So we've been also see Mrs Muscle a 48. Okay, so let's say this is Ah, Mr Muscle, like 48 year old male who presents with a change in weight and you know, to take a focus history from the patient on. Then we'll summarize our findings. So just general concepts in thyroid disease. Okay, I'm sure this is something. You guys are very, very, very familiar with it. Okay, general, the ways you differentiate symptoms of hypothyroidism and hyperthyroidism, so hypothyroidism things are general slowing down. Okay? Hypothyroidism. Things that generally speeding up. Okay. But with these feeding up, Okay, there's some features or hyperthyroidism that are very specific to a condition, because remember, grade disease, common cause of hyperthyroidism on graves disease is an autoimmune condition and has its own very specific symptoms. Okay, such as grave ophthalmology, which we'll talk about. Okay, uh, pretibial myxedema is is another grave specific feature on Doug the features like acropachy, which we'll talk about, um is little I good lead retraction. Is that specific to grave? See? No, it's not Okay. So a lot of people get confused about this, okay? Even though it graves optimum opathy is specific. Okay, there's There's a specific signs that correspondent Graves Obama be again this specific I signs that correspond generally with hyperthyroidism. Okay. Literature actually, like they're not specific to grave's disease. Okay? Even though they most commonly caused by graves disease, but they can occur in other causes of hyperthyroidism. Okay, but what? The graves off the market, the features such as? Except Elmos. Okay, which we'll talk about and treatable myxedema there specific to braves disease. Clue. So very important. Bit of data interpretation in your under crime station is to interpret different blood tests. Okay, the the one we're going to cover today is our thyroid function test. So I'm going to show you guys a bunch of difference. TFT. See? Okay. Example t empties on. But we will, uh, and you guys are gonna tell me what the likely diagnosis is. Okay, Describe these are thyroid deficit for me. So I have a blood test, and you guys tell me what you guys think is the diagnosis. How would you describe the diagnosis? Some of that's what you mean by mentioned disturbances in hyper and hypothyroidism. So they're both at the menstrual problems with thyroid disease. It can be. There is. There is some overlap that generally they say with hypothyroidism, you get menorrhagia. Okay, that hyperthyroidism. It's been more sort of irregular periods. Okay, but you're looking at mental changes with both. Um, but yeah, in terms of diagnose Said, this is a primary hypothyroidism. Okay, so in terms of the blood test, So we have a low TSH again high t three and t four and starts in keeping with a lesion. So problem within the tarragon. So it's producing too much t three t four. That's causing suppression on the pituitary leading to low TSH. Okay, over is very, very important to to be able to interpret TSH. TSH is the most important sort of blood test mark and thyroid disease in general. Okay, So low. TSH with increased our home and it's primary hypothyroidism. Okay. Ah, Nexium. So here we have a high TSH. Okay, about 2. 43 are normal. What do you think? Uh, so this isn't so their hormones are normal. Okay, so it's not primary. It's another primary disease. Yes, it's This is the This is what you call subclinical hypothyroidism. Okay, so it's subclinical. So decisions. If you say the patient is experienced that way, we can assume the patient is having symptoms. So that's why the having blood tests, but, um, so TSH is high. Okay, that's abnormal. But the thyroid hormone levels are normal. Okay, so indicates this is subclinical and again because the TSH is high, it means that we call it subclinical hypothyroidism. Okay, Um, but yeah. Remember, subclinical means the t 40 33 will be normal next one. How would you describe this one test? We have a low TSH, uh, low T for low t three. Yeah, I accept. Sick sick. You that your thyroid syndrome as well get depending on the physical contact, I would accept that. Okay, you can get completely deranged. TFT is with that about two years with their If we just assume that patients not critically year on. Well, this is Central Hypo Thyroidism. Okay, so central hyperthyroidism. So either problem in the pituitary gland or problem in the hypothalamus. Okay. But most commonly will be a problem in the pituitary gland causing secondary hyper thyroid is, um So why? So if you think about it, if you have low TSH, uh, which is leading to low T for low T three means that there's a problem higher up. Okay, there's a lack of TSH production, so there's a lack of Barrett home and being produced. Okay, so it's a central problem. So it's central Hypo Thyroidism. Okay, uh, next one, as though, uh, what do you think? That's how you different central from secondary. So central hypo the organism can either the secondary or tertiary hypothyroidism. Okay, if you want a different sheet between secondary hypothyroidism and social hyperthyroidism, you can check the T r H levels. Okay. The thyroid trip in releasing levels. Okay, but to shoot hypothyroidism is very red. Okay, Usually most causes off. Second oral hypothyroidism will be secondary hyperthyroidism in terms of the doctors said, What do you think? Yeah, so this is primary hypothyroidism. Okay, so we got low thyroid hormones. Ah, about a high TSH. Okay, So similar concept. So low. TSH In the context of abnormal thyroid hormones, I would think about primary hyperparathyroid omens. But here, a high TSH in the context of low thyroid hormones, I think about primary hypothyroidism. Next one, um, you guys think Yeah, this is subclinical hypothyroidism. Okay, you can probably sort of match up what I'm talking about, but yeah, this is something local. So again. Same. Same concept. Okay. If someone has subclinical disease, it means that the thyroid hormones are within the normal range is okay, but the TSH is abnormal. Okay, so here the TSH is low. So we're thinking about subclinical hyperthyroidism. Okay. And last one, you can probably do it by role of elimination, but what do you think it's happened here? We got high TSH with high 84 high t three. So Yeah, this is central hypertension Is, um okay, same concept. Okay. So excessive. TSH production is needing to access production off the 43 from the PARAGARD. Okay, so make sure you're very clear on the different patterns off Tyra Disease. Okay, on be able to differentiate, we, most importantly, be able to understand these clinical significance off the TSH. So we're not going to go through this, okay? If you want to go back and review the physiology of thyroid, go check out my endocrinology for finals Opana. Okay, But if this is, these are the different patterns of tired disease we were talking about. Okay, on. In terms of some other investigations, you can mention your ski again, split it up into your bedside bloods imaging, special tests, But, general stuff you can talk about with thyroid disease you talk about you do any. See GI? Okay, um, you know, hypothyroidism and get bradycardias hyperthyroidism. You can get different types of tachycardia is okay. You can mention you would do a focus, started examination. Okay. And we'll go through the thyroid examiner. Bet you mention different blood tests. Okay for blood. Come to think about infection. Thyroid function tests. Most important thing to mention again, general, Uh, thyroid auto antibodies, which we'll talk about the different antibodies for thyroid disease. Uh, why why would we do B 12 glucose? What would be the significance of doing B 12 and blue goes and thyroid disease? Yes. Some of mess. So, basically, just be just you can Ah, it's a bit extra, but you can just say maybe talk to Because Because I can be associated with other autoimmune diseases. Okay. Such as pernicious anemia. Okay. Which can cause B 12 deficiency and type one diabetes, which can. So that's why you've measured the glucose levels. Okay. And, B, if this is just stuff to really just a bit show up, show off to the exam in a bit. Imaging special test. So these air so imaging in general, Not that commonly done for thyroid disease. But in terms of your imaging, you can consider doing an ultrasound. Okay, What's the one? One of the common situations. You ultrasound. The paragard. Okay. When do you typically see ultrasound? Yeah, so it's using the evaluation off that thyroid nodules. Okay, so there's different various different cause of diarrhea. No Dios. And we talked to some of them. But particularly if you want to evaluate thyroid nodules a really a nuclear scan. What's the use of that? What we do? A radio nuclear scan? Yeah. Good. So again, it's Z commonly is used typically for nodules, but particularly looked for function. Okay, look, if there's active, if it is a functional component, Okay, there's no deals producing thyroid hormone if they're not producing can. As someone said, basically, if it's a nodule producing tired home and we're gonna call it a ah hot nor do okay if it's not functional, Okay? If there's if there's a reduced uptake on the nuclear scan, then we say it's a cold, not you. Okay, what's the significance? What's if someone has a hot nodule or cold nausea? Which one is more? Which one do we suspect? More for cancer? If someone has a hot, tired, no deal of someone has a cold I would not do. See Cold Baron audios. Okay, if someone has a hard time and not do it if there's increased uptake on a radio nuclear scan and then we don't worry as much about cancer, okay, Means that cancer is unlikely. Okay, Because it probably means that they have something like a, uh, adenoma get toxic adenoma or a multi nodular goiter. Okay, if there's lack of optic, okay, that's not really functional. Then we would be suspicious off cancer. What would we do next if someone if you're suspicious of thyroid cancer because of cold, they like to have a cold now, do you? Yeah. Good. So a f knock. Okay, so fine. Needle aspiration. Okay. To evaluate specifically looking for, um, cancer cells on the Reglan. Cool. So the investigations in general artery disease, Um, in terms of your antibodies. So this is very important. Lot of people get confused about antibodies and thyroid disease, but there's two main different autoimmune diseases and thyroid disease. Okay, Graves, disease and Hashimoto's thyroiditis. Okay, So the grave's disease, Um, but but the the key thing is with the antibodies is that it's not that one condition has antibodies and the other condition better. Okay, it's more of a sort of overlook. Okay, but it's more that one condition is a bit more strongly associated with a particular antibody, and the other condition is slightly less associated with it. Okay, so the anti TSH receptor antibody is much more commonly associated with graves' disease. Okay, most patients with graves' disease will have positive anti TSH receptor antibodies, and similarly, most grave patients will have anti TPO antibodies is, well, okay, but patients The answer TSH is that the antibodies they can show up in Hashimoto's okay, but they're much rather okay. Most patients with Rays, we'll have the answer CSH. But most patients with Hashimoto's will have the anti TPO antibodies okay on. Both patients can have anti tire goblin, but it's much more commonly seen in Hashimoto's thyroiditis. Okay, so again, entity S H, anti TB Oh, more strongly particular entity, it's It's most wrong or socially with graves' disease. Anti CCP on anti t t anti tire goblin. Most long you associate with Hashimoto's thyroiditis. Okay, but again, it's not that one disease has is diagnostic. Okay. And as a general rule in medicine, okay, antibodies are never really diagnostic of one condition. Okay, It's all about you know, one antibody is a bit more sensitive. Okay? Almost most specific for a particular condition again. And the anti TB Oh, can be positive in postpartum tired, lightest anti tire globin can be president tired cancer as well. Okay, but again, typically, we're using antibodies to different to investigate for ultimate diseases like grave's disease. And Hashimoto's in terms of manic management. Okay, we covered this in much more detail during our finals. Easy session. Okay, so if you want to learn more detailed, check out that weapon or not. But this is how I presented management for Hashimoto's thyroiditis. Okay. Remember, the mainstay used to give live at the rocks in the basement. Okay. To replace style home, um, And for graves disease at typically, um, you There's different options available. Okay. Typically, first line, anti thyroid age and we're using. It's carbimazole. And there's different regimes we can use, um, at the other options. Well, like propranolol for symptom relief. A radio idea. Therapy can be a definitive option as well as surgical therapy. as well to basically remove the entire gland again. Recovered the sort of detail of these different treatment options in the finals. Easy session. So I recommend you sports that webinar to get two. Just go into more detail of it. But today I the rest of the session, I just wanna run through the prior examination. Okay? I make sure everyone's clear on the different steps and the different physical findings for the tire exam. So when the gp setting Okay. You know, see, Mr Right, Any counting 53 year old male who presents with tiredness on? We've been us to do an examination off the tire. A gun. Okay, so, uh, we're going to go through examinations again. These are just did general tips for all physical examination's. You can have a read of them in your own time. Okay. I've gone through this many times in previous sessions Are have a read through in your own time, but again, the thing put on a show, okay, That's the most important tips I have in general for physical examination's put on a show for the for your examiner. Okay. Just really show if your knowledge and showoff skills. Okay, but we have a couple of different spot diagnosis scenarios and people in our examination. Um, so you see, there's quite a lot of different scenarios, but this is pretty much going to cover most of the different third diseases that you need to know for your skis. Um, so let's go for the let's go through the first one. Do you have a 44 year old man who presents deter nontender goiter on examination? His very thin has very popular eggs, and there is evidence off a fine tremor. What do you think it is? The diagnosis here? Yeah, this is grave's disease. Good. Okay, So Grave's disease as we talked about important cause of hyperthyroidism. Okay, so this patient has a goiter. Okay, so, in a large thyroid gland, very thin, like a a feature of hyperthyroidism. What is this? Very poppy legs. What was that? Describing? Yep. Pretibial myxedema. Okay, so remember, pretty well myxedema is a specific sign for graves disease. Okay, um, evidence of a fine drummer. So this again, a general future of hyperthyroidism. But the key thing is that because of the puppy legs, we can specifically say this is grave's disease. Okay, rather than any other cause of hyperthyroidism. Uh, next one 40 for your man presented hyperactive nous on examination nontender masters palpated in the paragard and and multiple nodules about retrosternal dullness most present to the level of the sternal angle. But he's saying, Yeah, so this is a actually a toxic multinodular goiter. Okay, um, so t m m t mg. So talk to multi drug says where there's basically those different nodules on the tire gland which are functioning autonomously. Okay, which are basically producing tired home on independent of each other. Okay, Independent of other Norco's on saying your multiple nodules. So this patient has multiple nodules on palpation of the paragard because that's pretty suggestive of tea mg and oxidase indicates that this is a very big goiter. Okay, there's practice. It'll dullness to the level of the sternal angle that indicates that it's a big goiter. Okay, which can be seen with a multinodular goiter. Exelon. 21 year old man presents and neck pain on examination. The paragard is very part painful to puppy. Recently had a cold. Yes, I was elevated. Yeah. Good. Okay, so this is likely. This is like a picture of tired. I just Okay, but specifically, we would call the sequel vein style like this. So thyroiditis. Okay, So tired. I just inflammation. So the key thing is that this patient has a painful, tired round on probation. Okay, so if someone has a very this's one of the major causes off a painful Baraclough. And okay, if someone has pain on palpation. Okay, that indicates sort of thyroiditis. Okay? And this picture of having a recent infection high es are that that's classical be Quervain's started itis. Okay. Also known as sub acute otitis again. Painful tarragon. Very indicative. Off be Quervain's start. I tests. Um, cool. Next 1 55. Well, woman presents you the double vision on examination. The globe is pretreated out. She has reduced upward case. What do you think? That Okay? Yeah, this is graves, eye disease. Okay. Um, so we'll talk. We'll talk about grades. I disease in a bit more detail about this patient has diplopia. Okay, double vision. Well, it was pretreated out. As as we said. This is excellent. Almost. Okay. Protruding out blow. And, uh, importantly, you can get problems with eye movements, okay? Or different types of ophthalmoplegia, but classically awkward gait is affected. And graves eye disease. Okay, Uh, next one 15 over both Because enter the non tender back neck mass on examination, the swelling moves with boats were swallowing and tongue protrusion. What do you think? Yeah, this is a varicose. Oh, sister got varicose doxazosin. I said so. It's a younger young boy. Okay, so that would also duct assess can typically present quite young. Okay, dark. Lots of duct is usually obliterated in pregnancy. Okay. And something people that can persist and secretions can accumulate in the targets of duct and cause a dog also assist. Okay, um, why is this the arrogance assessed? I'm not just any type of like an enlarged going toe. How do you know it's actually a paragraphs Assist. It's the movement with swallowing is indicative of both. Okay. Any type of any muscle in the thyroid gland will move with swallowing. Okay. It's the tongue protrusion that makes it tells us that this is specifically at their ago since test okay, because it says specifically moves with tongue protrusion. Okay, because it's connected. Teo tongue do too. And Realogy. So that's why this is a varicose assist. Next, 1 20 sexual woman presents with your Sinus in her in her voice. Hey, on examination, there was a next car, but the gland is not possible. What do you think? What do you think about the next car? Um was Nissen voice? Yeah, this is good. So this is quite interesting scenario. So this is patient is likely had a thyroidectomy. Okay, so the reduction I'll show you a picture of the next up with prosecute, but I would expect, but next goal here is to just started ectomy. This is also in keeping with the fact that they have Ah, the glands. Not possible as well. Okay, We'll see you in voice. Yeah. Good. So, uh, that damage to the recurrent landed on the Okay. Uh, temple, potentially strong associated complication off thyroid surgery is damage to the recurrent laryngeal nerve, which is very close to associate it with it are a gland. Okay, actually, that's a potential scenario off a thyroidectomy patients next. 1 44 year old woman, presented timeless on examination there has lost off the outer third of the eyebrows. And she's wearing a very thick jumper. Despite the room temperature being work. Yeah, I get. So this is patient. But like the hypothyroidism. Okay, so we talked about it happened. Thyroid. Some things are slowing down. Okay, So that that IgE, most of the altitude, I rose very, very important. Sign of hypotension. Where is, um okay, but it's very rat, in general with hypothyroidism. Um, what is this stuff about wearing a big jump on this way? Room temperature being room? Yeah. Yeah. So this is a cold intolerance. Good. Okay, so with hypothyroidism, you get cold intolerance with hyperthyroidism. You get, um, heat intolerance. Okay. Ah, next 1 26 year old woman presents with dysplasia for the past three months. On examination is a mass in the right anterior neck that is mildly tender to prop patient with and large lymph nodes. Cervical lymph node. As she received radiation for Hodgkin's lymphoma as a child. Different than the other ones. A good thyroid cancer. What it is which specific, histological type of thyroid cancer. Is this patient likely having? Yeah. Yeah. Good. So this is likely as case off a pill retired cancer. Okay, eso Why? I said this patient has dysphasia. Okay, Um, so potentially from the from the barrel. Cancer, visible mass. Okay, at with tender to palpation of enlarged lymph adenopathy. Okay, prepare it. Tired. Cancer is the most common type of thyroid cancer typically is very rapidly progressive. Okay, this is in terms of the timeline patients. This one patient developed this very quickly. Okay, That's a vital importantly, Another important feature of papillary thyroid cancer on, uh, the important sort of risk factor here is the radiation therapy. Okay, So patients who receive the neck radiation, that is a potential risk factor for papillary thyroid cancer. Uh, last one. And also, this is a young patient. Okay. Is a young woman as well terms of the age demographic? Last woman, Last one. So we have a 34 year old told man who presents with an enlarging neck mass on examination, there is evidence of because of neuromas and admits it started. Click on auscultation. Uh, what is the cause of the neck muscles? Tricky. Anyone have any idea? Uh, yes, you're right. This is mentioned drum, but and no man one, But what's so if it's a men's and the most likely cause of the neck must Yeah, adultery thyroid cancer. Very good. Okay. Medullary thyroid cancer. Okay, so the key thing medullary thyroid cancer is a can occur as a complication open. And the crime syndrome got known as have men. Okay, multiple endocrine, neoplasia and and classically can be associated with multiple endocrine neoplasia type two, which can be characterized by different complications like Marfan syndrome, mucosal neuromas on Marfan syndrome. As a complication of Marfan's. You can get a midsystolic click, which is the mitral valve prolapse. If you if you tune into our heart members session. Okay, you'll remember this. Okay, Much of a prolapse is a complication off Martha can. It's common in patients with Marfan syndrome. Um, so, yes. So this is patient would like to have medullary thyroid cancer and underlying men to syndrome. Okay. Very, very different. It's a crowded, challenging scenario. Okay, not something you get in your skin spot. I'm trying to cover. Basically, these are all the different types off, uh, different types of cases that you might that you can pick up from doing a barrier examination. Okay, so let's go through the different steps of the exam and put all these different, uh, pathologies into a deeper context. So in terms of the introduction for the our exam, Okay, this is a little scenario. Okay? There. It's all very similar. Away. You introduce this alcohol? Physical examination's a good sentence I like to add for the diet. Examine is just ask if the patient is able to swallow. Okay, if they have any problems with swallowing, because during his arm nation, you'll have to ask the patient too. And sips, um sip, sip, sip some water. Okay. So I would think it's just good to ask if they're happy that they're able to swallow. And yeah, just a little other statements are just general statements. You due for any physical examination. So let's do some spot diagnosis for the our examination. So I'm going to show you guys some pictures and you guys are going to tell me the likely diagnosis. So, what do you think I'm going to get out with this picture here? Yes, We're talking about general inspection now. What do you think? Yeah, So some of the guys that are they comfortable at rest? Okay, this is just a general thing you look at on inspection, Okay? Your end of the bed a grams. Are they comfortable at? Rest? Uh, next one. So we have this room here, okay? And have a guy, uh, in the room wearing a big, thick coat. What do you think? So this is likely, uh, I'm trying to get that cold. Intolerance s so basically you're Oscar. You want to be looking at the clothing off the patient. Okay, If it's if the clothing is basically matching the temperature off the environment. So this guy's wearing get sort of a mountain climbing type. Uh, clothing. Okay. Very thick coats. Okay. Inside the room. Okay. So, trying to get cold intolerance it. Uh, similarly So we got a picture of a winter, but it looked very cold looking back around here. And we got these two women here. Bikini goes. Yeah. I think I'm going to get out here. Yeah, I did. So this is trying to get a heat intolerance here. Uh, if you want to know, I did. I did exactly what you guys are thinking about. I did copy. Copy an image of to bikini girls, crop out the background and paste it onto a winter background. Okay. These are the length we're going to to teach these concepts, but yeah, this is Ah, scenario off heat intolerance here. Next one. What do you think I'm getting getting out here? Yes, Sweating. Good case of the gods. I put thyroidism. Okay, dive three. Cysts generally features off height. I would love I get home. Uh, next one. Yeah, the weight loss. Okay, so the general, I'm just thinking about habit. It's okay. You want to look at the habit test and think about if there's been any change in acute sort of acute or chronic changes and weight's okay. Important, important, tired examination to think about weights. Okay. There's if they have a history of weight loss, weight gain and stuff to look at is again, as we were talking about with acromegaly trying. Think electorally okay out there. Trouser sizes changed. Okay. Is that belt's looking tighter than normal stuff like that? Okay. Stuff you can pick up on. Uh, last one here, Abbvie. So, what is this box of medication getting up? Yes. So I'm going to just look for medications. Okay, but here we got propanolol. Okay, So specific medication for symptomatic treatments off hyperthyroid symptoms, but just generally look for medications around the bedside, a common one and a thyroid station would be better blockers. And that would indicate that it's likely a hypothyroid patients. Cool. So we did our general inspection. So you took a general inspection. We looked at the patient's gave you looking for stuff at the patient, and we look at the bedside. Okay, I said clothing. Okay. Well, technically so then you're looking at the patient again. But just general peripheral things you're looking at, we're gonna move on to the hands. Now. What I will tell you now is that in your osteo bi, you're not going to see many physical findings. Okay, this is most stuff that you'll see in patients who are very poorly controlled disease. Okay, But realistically, most patients with thyroid disease they'll be medicated, so they're not gonna have many. In reality, most patients don't actually have many physical findings. Okay, because most patients are treated both married pretty well. But we're going to talk to some potential findings that you can see if someone significantly disturbed. Okay. So what do you think? I'm trying to get out here. What do you guys think of these hunts? Ah, not So this isn't a tremor. So let's assume the patient's hands up flat on the table. Erythema. What do you think about the fingers, Dema? Yes. Oh, because of the This is tired. Acrobat, you okay? If you probably could get better pictures of a paradox. Paki is basically like clubbing. Okay. Sorry, Doctor. Bucky. Um, again specific two graves disease. So look for clubbing. But if you have club fingers with graves' disease, that's that's basically acropachy. Okay, it is. The pathology is a bit different to normal. Data clubbing. Okay, but basically looks the same. So because of the edema and proliferation off soft tissues and the droppings, you get the appearance of digital clubbing. Okay? And again, it's specific to grave's disease. Next one, would you think about their look at the nail beds close. Look at the nails closely. Yeah. Good. So this is a nickel isis. Okay, Neil, finding that you can get with hyperthyroidism. One other condition is a nickel isis commonly associated with If you think about our hat on examination. Yeah. So psoriasis. Okay. Unequal. Isis is one of the most important nail findings supposed to isis. Okay, But at Hypothyroid patients can also have may have done it equalizes as well. Next one, um, again, very non specific finding. But what do you guys think about this hand? Uh, not muscle wasting. Um, everything looked good. So this is Ah, Pomeroy. Okay, uh, again, we talked about it during the abdominal station. Okay. Very strong associated with chronic liver disease, but poverty, McCann happen with type of thyroid patients is Well, uh, next one. Yeah. Good. Tossed any Okay. Um what? Why is it important to look for task staining in a thyroid patient? Why is it important to look for evidence of smoking? What's the clinical significance of smoking and diarrhea? Disease? Yeah. Good. It's a risk factor for thyroid eye disease. Okay, So one of the most important the bits of advice you give to patients with graves' disease is to tell them to stop smoking. Okay, because smoking it's a big risk factor and can worsen graves off democracy. Okay, so that's what we're looking for. Tossed eating. Uh, next one, we're going to try to get out here. So this will installing a cop again, trying trying to get us to think about laterally, uh, cold intolerance Yeah. Yeah. Just generally think about the temperature of the hands. Okay, so the hands are cold. Um, just how they're feeling Moist. Okay. Just think about the temperature. Uh, last one here was the hands would be I think about this patient's hand. What? Yeah, Yeah, it's It's a popular tunnel syndrome. Okay, so this is scar for someone who's had surgery for a couple tunnel release. Okay, Um, so this is what this cock it looks like. So remember, we'll talk about this doing the MSG Nation, but hypothyroidism is in the differential for couples on syndrome. So, again, important feature to look out for. Okay, so we talked to those other things we're inspecting from the hand. Okay. We're gonna talk to a different examination steps to check the pulse. Okay. So, again, general technique powerboats with your 2nd, 3rd and 4th fingers. Uh, no. Your thumb. Okay. And comma. And on the rate of them and volume off the pulse. Okay. Um, important. Okay. With hypothyroidism, you can get low heart rate hyperthyroidism. You can get tachycardia is okay. Okay. Have a look at this video and tell me what you guys think. Yeah, Good. So if you look really closely the patient heart, a fine tremor. Okay, so, um, check for a fine drummer. So which side's deep of the pace of paper And you put it on the dorsal aspect of the Palmer aspect. You excited about the piece Paper on? Yeah. Docile aspect. Okay, so with hands like this things, piece of people on top of the hands and check for the fine, low amplitude trauma. Okay. Might be seen in hyperthyroidism. Okay, It's not that common for your nose, but it can. It can be seen. Um, next one, Uh, this is this is a very interesting video. You look very closely at be fingertips here. Yeah, take a video. But he has thing. Yeah, I get a prolonged cap. It's completely full time, so I'm gonna get you Want to check the capillary refill time here? Okay. So you see the even the position press on the patient's left middle finger. It's the profusion. Didn't return. Okay, But when the presently right track and just the insulin that refused very quickly, okay? Within less than two seconds. But it was prolonged in the left hand. Okay, So, again, just check with me full time check for problems with confusion on also with the still talking about the arms. Okay, so make sure that offer to measure BP. Okay, general thing you do with almost examinations is to offer to measure it to the Examiner. Okay, so you can just give the examiner statement. At this point in the examination, I would like to measure the patient's BP in both arms. Okay, so I was the hands. And, um so with the hands reinspected different things, we check the pulse protective capillary refill time. We checked for a fine tremor. Okay? Using the piece of paper that they will be available for you and we offer to check BP in both arms. Now, we're gonna move on to the neck. Okay? This is the is the major aspect of the examination. Okay? The actual examination, not the neck. So I try and follow and go go through it, step by step. So one of the first things you're going to do check JVP so osteopenic you to look over the left shoulder, examined the position of the GDP. We've gone through this many times and other examinations, But remember this video when you're looking at JVP generally it's a venous. Also, it's going to collapse inwards. Okay, so it's moving in words. I remember veins. They collapsed. Okay, so it's moving in words, whereas with the carotid pulse, it moves out words. Okay, cause it's an artery pulsating outwards. Okay, Yeah, but check the JVP position. Public coratids. Okay, so remember it across it also when you, you know, little differentiated to note across the postage, pulsating outwards. But make sure you pop a tree cross. It's okay, as you can see, the carotid pulse here, Uh, inspect for Scott's. Okay, so we're moving on to me. Check the baby people. Pay two carotid gland. Okay, now, we're just doing a quick inspection of the neck. Can you tell me, um what is this scar here? Yeah, so this is likely a thyroidectomy spot. Okay, so you see, Yeah, if you think about the anatomy, Okay, It's typically a hose on some incision here. That's a thyroidectomy. Scott to make sure you can recognize it properly on. We got some pictures here. One of these different pictures representing here. Yeah. Okay, So these are all different types of goiter Okay, So you want to inspect for a goiter? I'm so and then large to borrow gland. Basically. Okay, so if you look really closely here, you can see it's slightly enlarged. Okay? Asymmetrically towards the right side. Okay. If you look like Teo, really look generally and again. Look at it broadly. You could see the right side is slightly more in last year. It's a bit more diffuse. Okay, the goiter. And here the goiter is a bit more nodular. Okay, so it's a nodular goiter. Can you see the sort of bump bumps in the Reglan? So you need to think about when you see it going to try and think about what's the cause of the goiter and coming onto that, Can you just tell me what are the different causes of a goiter? What can cause a enlarged a thyroid gland? On examination, I I didn't. Efficiency is a big woman, okay? Any other cause it? Yeah. So in terms of the again in osteo is it's all about structuring your answer. Okay, so I like to think about the causes of gotta in three different ways. So you think about causes of a diffuse goiter causes off a union nodular, goiter and causes of a multi nodular goiter. In terms of causes of a diffuse school teacher, that is different things like grave's disease. Patients have some kind of tired. I tests that they have a TSH creating out of normal. So secondary had about hyperthyroidism. Or if they have idea deficiency. This can all cause more of a diffuse quater. You need nodular. Goiter were thinking more about things like sits at a know most concepts. Okay, more of your sort of different causes of no deal. Okay. And your multi nodular goiter. So you can either have toxic multinodular. Goiter is okay with just producing tired homo. It's a non toxic. Okay, so it's not functional. Okay? The adenoma is not producing parathormone and Saluzzi. A different causes up a goiter on here, So we're gonna move on since you were still on inspections. And now we asked the patient to sip a glass of water. And the key thing is, so when you want to look from the fronts and to the side Okay, so we can see here. This is before swallowing a cup of water as a sip of water, and this is after swallowing a sip of water. Okay, so you can see the sorry gland moving up, okay? And that's the key thing when you swallow a sip of water if they're going to move up. Okay, so that's how you can tell. So if you see a midline mass and it's moving up on swallowing, okay, that indicates that it's likely attached to the paragard. And so, yes, so keep thing is an important that examination steps is still look on. Inspection is to ask the patient's super glass of water and look in with the if there's movement Awkward and again, you observed from the front and the side on here. What do you think this kids having here? So you can see the lump here, Onda. I mean Austin patient to stick their tongue out and you can see the the masses move upwards when the kids are being asked to stick his tongue up. Yeah, good. So we talked about this with the spot diagnosis, and this is likely a varicose of duct cyst. Okay, so keeping is again. It's a midline must. Okay, so just like the ones and the previous slide if it it will move up on swallowing a swell. But the key thing is with a paragraphs of ducks test is that when you lost a patient to protruding tongue out, the cyst will move upwards. Okay? Because the paradox of duct cyst because of its embryology, it's attached to a specific location and the tongue notice deformed cecum. But when you're all set patient to stick the tongue out, it'll move upwards. Okay, so remember to ask the patient to stick the tongue out and again observed from the front inside. Okay, Now we're gonna move on to palpations. Okay? So when you palpating the tarragon, remember, you can't play from the back of the patients. Okay, Um, you don't pop it. You don't prop them from the front. Okay, move to the back and palpate, dora gland palpates be isthmus first. Okay, remember when you pump it, you using the flats of your hands and palpating in a sort of a circular motion on and try and feel trying palpate the diagram. Trying palpates the is mus palpate each local the thyroid gland and try and palpate any lumpy, bumpy bets. Okay, And remember, you part of it your palpating it during three different places. One you palpating during rest palpate when they swallow. Okay, so remember, we want to check if it's moving upwards when they swallow. Okay? Because the character and moves back when it's swallows when you swallow and you want to pop it during, but tongue protrusion. Okay, so if it's moving up during tongue protrusion, as you said, that indicates it's a terrible so doctor cyst. Okay, so that's your part patient. Okay, remember, you're doing it from the back part of the hands circle emotions. So can you just tell me how should any neck lem be assessed? One of the different things you want to comment on when you are elevating a neck assessing a neck lump in general, what are the different things you want to pick up on assess described to the examiner? Symmetry, size, consistency, SNC's and tea's good bit motility, edges, consistency. Yeah. Good. Okay, so this is a bit of a bit of a more surgical topic. Okay, But generally, when you think about any surgical mass, that sort, neck, neck must I like to think of it as the three s is so as for. So the three s is three C's on be three t's. Okay, so as far sight size, shape and symmetry. Okay, So if the Reglan is there a large goiter. Okay. Is it symmetrical? Okay, Asymmetrical. Where is that located? Is it located in the anterior triangle opposed to your triangle? Okay, things like that. Three c. So cotton toes color. Okay. Is there any sort of overlying, erythema, changing color consistency? Okay, what does that actually be like to pop it? Okay. It's a very lumpy bumpy, not killer. Okay, things like that. And the three t so Chief of tenderness. Okay. Remember, Major cause of a painful thyroid gland is married itis, um, other teams for tethering. Okay, is it said that to the skin. Okay. We'll be worried about things like cancer on it doesn't transilluminate. Okay, We don't need to transilluminating the masters in a barrel examination, Okay, But this is general stuff with thinking about with neck muscle is and then so that's our powered palpations. Okay, then we want to do a quick lymph node power patient as well. Okay. And, uh, make sure you're not, uh, palpating like a piano. Okay, Palpate your lymph nodes properly. Um, also, you know, someone said bruit. So make sure to it, we'll talk about release, but if someone has a probable thrill on palpations off the paragard. And what could that suggest? Yeah, Grave's disease gets Okay, so someone has a palpable drill. Okay, so this is another thing you want to help pay for it. They have a thrill that could suggest grave's disease. Okay, So once you've done your thyroid gland polyp patient, do your lymph node examination on Ben, we're going to do some other stuff. So, what do you think about this Chest X ray? Yes. This is Retrosternal. Gotta. Okay, so this is a huge goiter behind the sternum. Okay, So the key thing here is, And yet, as you said, there is tracheal deviation as well. Okay, there's special deviation to the right to the right. But this patient has a huge retrosternal go to. So the key thing is, you want to perform retrosternal percussion. Okay. To check if they have a record store or goiter gets a puppet from above the sterile angle downwards. Okay. Checkup is dullness to check if they have a breakfast and or goiter on. Then we want to check for trickle deviation. Okay. And remember, this is the technique to check for trickle deviation. Okay. Again, thinking about the, um, practice tunnel goiter. Okay, There's a big goiter that might lead to a trickle. Deviation. And then we want auscultate the thyroid gland. Okay, remember, one also take for bruises on. Remember, we want to auscultate Each low for bruit is because, um of increased vascularity okay for graves. Disease Eso? Yeah. Remember, thyroid bruit is in general. I would think about grave's disease because, remember, the parotid gland is a very vascular organ. Okay, there's a lot of blood supply in the tear glands, but in grave's disease, there's even more vascularity. So you can get a big bruit with graves' disease and a good quick tip when you're asking, patients are all started when you're also taking Is the Austin patient hold their breath? Okay, because, um, that might make it easier. Trashy osteo. Listen to grease. Okay? It's a bit difficult to auscultate for. Bruise if you're listening to the patient's breathing at the same time as a quick tip is the ostentation to hold the breath. Okay, we got. I got a video to show you guys in. You guys gonna let me know what you guys think is kind of it happening? Have a look at the patient's forehead. In particular. Yeah. Good. Okay, so this is a pemberton time. Okay, so we're gonna offer to check Pemberton sign. Okay. So keeping it's a commitment sign. So when we ask the patient to lift their arms up in the year the patient's face became flush. The case of you Look closely. You can see the forehead became very, very red. Okay, Because we're thinking about stop. That's compressing the superior vena cava. I'm so when they left their arms up. Okay, that exaggerates that compression on D increases the eczema. Okay, patient flushing. But when the patients brought his arms back down, reduce the obstruction again, their forehead cleared. Okay, the color returned back to normal again. So what? That's called Pemberton's. I'm okay. So this patient had a positive benefits and sign Onda in terms of your thyroid examination, you be thinking about a big goiter again in case that they have it. If they had a big breakfast and we're going to compressing the superior vena cava that might cause a positive permitted sign. But in your osteo only need to offer to do this. Okay? You don't necessarily after actually asked you, um, left the patient's arms up. Okay? Just you could just offer Tell the Examiner that you would, uh, do this in real life. Okay, Cool. So we did a big chunk of the examination that Okay, that was our neck exam. So we did a whole bunch of different stuff with the neck that can be inspected, and we did All of these different steps is Well, okay, uh, what's the next step? What we're gonna move onto next. Um, I'm gonna move on to the legs. What am I gonna move on to next face? Okay, so So I recommend with our examinations to do the neck first. Okay, because that's the most sort of involved bit again. Then move on to the face, and I see. So we got some physical findings off different facial peaches s, so let me know what you guys think. What do you think's happening in here? Uh, no. Quite little. This isn't like, Okay, well, come on to it. Yeah, loss of the lateral, one third of the eyebrows. Okay, so you look at the eyebrows said Okay. There the lateral, one third of each eye. Brody has lost. Okay, So as a feature of hypothyroidism. Okay, Uh, what about this guy? Was the facial features here? Yeah. Face. Okay. A puffy face again. Periorbital edema as well. Okay, these are both features off hypothyroidism again. Puffy face, periorbital edema. Okay, we're gonna move on to the eyes now. Okay. Specifically, talk about peaches off graves, eye disease. Okay. Graves. Ophthalmology. So would what is this feature here? Except almost get a case of protruding out blow. Okay, so in the greatest often not today. You get inflammation in the Retropatellar area, and that can cause the globe. True doubts. Uh, next one. What do you guys think here? So education has, except on this. But think about the lead in particular. Yeah. Literature acting gets a a, um, next one. Yeah. This is a bit tricky, but we can see two people are staring at each other. What, you think I'm trying to get up here difficulty looking up on a quiet? So they're having a staring contest of Why would they be staring while they they should be staring. Looked like they stay. Yeah, so they're not blinking. Okay, that's the key thing. So there's infrequent blinking with graves' off. Okay, so that's why they often look like they're just standing on you all the time, Okay? They don't drink that much. Okay? If they have significant, except almost and lift attraction, um, stuffed into another feature. Next one. Ah, again, there's there's except ah, Monsieur and little Traction. But looking closely at the, um, uh, sort of eyeball. What you guys? Yeah, chemo cyst. Good. Okay, so this patient has chemo. So conjunctiva lady, um, A and conjunctiva with injection is Well, okay, you can see the readiness, Cindy guys as well. Uh, next one. This is really something you look at. This is something that patient might complain off. Yeah. Diplopia. Okay. It's a double vision. Gets last one. Uh, what do you think? So the the the eyes under fluid Seen lights. Okay. On. Do, um, you see some What's happening here to the cornea? Yeah. Corneal. Also. Okay, Very good. Okay, So this is the cornea ulcer. Okay, so this is a big where this would be a very worrying feature. Okay, If someone has graves eye disease, their eyes could be protruding out significantly. And their eyes can become very, very dry on because it's pretreated out. It's much more risk off abrasions and things so they could get complications that affect the cornea by corneal else is okay with this patient has. Okay, so these are just some different beaches are graves' off the, um, opathy and another quick tip. Okay, there's a lot of people don't do this, but I reckon really recommend this A good thing to do is the also patient to try to completely close the eyes. Okay, so they're complete graves that have significant, except almost they won't be able to come close their eyes completely. Okay, because they're globe is so protruding forward. So just ask them to completely close the rice and see if they can. Okay, in terms. My next question. So I'm asking you, How does graves off the mop? The progress. So I have a new monitor. You guys on da. I just talked to it. So this is the way it progresses. Okay, Typically, um, this is a new monitor. The pneumonic is no spec so and for no signs of symptoms. Oh, if they only have certain signs, Like like little traction as the soft tissue involvement. Then we talked about some of these people. Proptose is also known as except almost even extra ocular involvement of their problems with gaze. Okay, problems that I've movements and see for corneal involvement. So we talked about it. So if they get complications like keratitis ulcerations of the cornea, that's the That's the latest age of graves off for myopathy. And the final one is the big concern is sight loss. So if patients have grave's disease, start getting sight loss. Okay, Visual with visuals, lost symptoms that suggest that the optic nerve is starting to get compressed. Okay, So I'm expressing to you guys is one of the signs off optic nerve compression on examination and on history, we'll suggest if a patient's optic nerve is being compressed. Yeah, loss of color vision. Okay, Painful, painless visual loss. Yet papilledema year. What are the examination finding our EPD Good. That's a big one. Okay, so it's that they have a relative afferent papillary defect. Yes, I have a nice new monitor. You guys Nothing you money. So the new Monica is a P l A c. So fuck to pee for pale disk l for lots of issue acuity or loss of color. Vision A for Afrin. People with the factor case. If they have a repeat, the that's another feature optic nerve damage and the final see for Central Scotoma. Okay, so if they have a lesion off the optic nerve that can lead to scatomas on dot Okay, so we talk about inspecting the ice, Okay? Next, we're gonna ask them to do the H test. So this is we talked about this with the diabetes station in terms of their policy. But when you Austin to the hates tests were testing difference. Extraocular muscle movements. Okay. And these are the different extraocular muscles. Your testing way. Graves disease. Okay, I have a video to show you guys. So have a listen and have a watch of the patients ice and tell me what you think the findings are. Take it. But then again, what do you think? Yeah, positions holding 10 in the middle. So the visit and just holding the pen in the middle. Okay. And the is it is it positions asking pen called Decadron. Look at the pen on acceptable. So they once it happened here is there's loss of convergence. It's not able to move it. I see the midline to visualize the 10 in the middle of his case. Okay, so that's a feature of, um, another feature present. A feature of days off. Um, a pretty is they can't converged division because of the autumn. Um Obama. Poesia. Next. I have it again. I have a video you guys on. Uh, I have a look. Anything scalp that happening? Yeah. Good. So this is little, like, Okay. So quickly before we talk about the left. Like you can see here, Like with the physicians. Look, the patient's looking up, right? We can see in the left eye. The left eye is not able to move up completely. Okay, so there's reduced upward gaze on the left eye. Okay. Classic feature of graves eye disease is they have reduced upward gaze on, so let the lid like here. So if we showed again, So it fits it when the patient's looking us to look downward quickly. The lid is like, Okay, it's not moving in a uniform manner. Um, So the key thing is, uh, we talked about checking for lead, like so the way you check for lead, like, is to, uh, use your finger. Okay. And ask them to follow your finger with the ice of us. So start with your finger looking on. So ask them to look up to your finger and then quickly bring it down in a straight line. Okay? Don't Don't Just move it, Swing it around, okay? Bring it down in a straight line so the patient can easily follow it. Okay, but bring it down quickly. Um, quickly. What? So imagine I'm the patient, and I've been asked to assess little like, Can anyone tell me what I'm doing wrong with looking for little like, What am I doing wrong? That? Yeah, I'm moving my head. Okay. So I should have moved. The patient should have moved their heads when you're checking, like, okay, they should only be following your finger with I've movements. Okay, So quick, tip us. Put your hand on top of the patients head. Okay, So they don't move the head too much and just ask him to follow with your finger, okay? So that's how you can effectively look if the liver is liking. Um, so that's how we check for lead. Like and in terms of the management of graves, ophthalmology, Um, just general steps. Okay, so remember, they need to stop smoking. Okay? Smoking is the key risk factor they can use. I protection. Make sure to treat the hypothyroidism in severe disease. You can use steroids. Okay. IV steroids. And they have very severe automobile. They have risk of visual loss, and they're not responding to start. You can do surgery to relieve the pressure. Okay. So they can basically remove some of the orbital bones and try and relieve some of the pressure in the eye. Cool. So we talked about the ice. Okay, basically, talk to the face. So we did a couple of different things. We inspected different things. I asked them to shut their eyes completely. We did the hates test, and we checked for little AC. Okay. And those are all more mainly features looking for graves off. Mom. Pretty. Uh, finally, we're gonna move on to the legs. Okay. What do you think about these different legs here? Yep. So this is Ah, pretibial myxedema. Okay, so we can see. Um Ah, sort of on the anterior legs. Okay. Very nodular. Puffy. Okay. A Demetrius, Um, on the until you shins. This is pretty typical. Makes it even. Er, take strongly suggestive off grave's disease. Okay, so just inspector it. Okay? Have a look Watching this video. This is a very interesting video. On what, you guys to have a close look at it. Yeah. Good. Okay, so this is a patient who has, um, proximal my place. So you want to check for approximately? I upped the Why do you think this patient has approximately about the with the way they're using the body, it in terms of their body mechanics. What suggest that they have a proximal my upper the here and that likes? Yes, There's a couple of different things. So they're they're using. So one. They have a very broad. Their legs are very widely spaced apart. Okay. To try and give them a broad base to help them left off the chair. Okay. Other main thing. They're using their arms. Okay. To try and use the upper limbs upper body to compensate for the weakness to try and lift themselves off. Okay? Other things is, um when you see when you see it, the patient move, their legs are gonna moving back to try and give themselves balance to lift off. Well, on also, when they actually start lifting off the back is shifting Fords. Okay, because off the weakness and the core muscles to compensate for that. Their truck they lifting off with the shifting the body weight four as quickly as they can to prevent them from collapsing because of the proximal muscle weakness. So the key thing is the the compensated with the upper limbs. Okay, that's the important feature to look out for, to check for proximal I Ah, pretty. And what about the gait? You look at the loss, few steps a quickly. Okay. Gage, she wasn't walking. Walking? What type of gates can you get with proximal myopathy? Yeah, waddling gates again. So it looks like that because the proximal muscles are weak, they're having to compensate by sort of soak, um, circumcising the legs to walk in a straight line. Okay, so that's the type of get you might get with, um approximate mark the so good. So that's how we checked approximately about this. So ask them to sit down, sitting board and their arms cross okay, typically and ask him to stand up. Okay, so that's how you check for a problem. I hope the in the legs, you can also offer to test shoulder abduction. A swell. Okay, You don't need to, but you make sure you ask him to sit up from a standing position. Cool. And last thing you want to check with the legs is check deep tendon reflexes. So I've got a couple of videos of different deep tendon reflexes to look out for with thyroid disease. As I have a watch of this video, What do you think? Yeah. So this is this is actually this is hyperreflexic. Okay, Um, so, uh, so this is actually hyper reflexing. Okay, there is. This is quite pronounced reflexes in the biceps. Okay, if you should get a B, i d. Regularly do biceps reflex. It usually is in that pronounced. Okay, this is five pronounce. Okay, this is hyperreflexia thinking about hyperthyroidism. Okay? Haven't talked to some of these other videos. These other videos are very interesting. They have a look closely. What's happening? What do you think? Is that hyper reflexing? No delay. It's delayed reflexes. Okay, So if I have a look closely again. So what's happening is there's the relax. A shin phases delayed here. Okay, so that the contraction is normal. Okay, It's contracting at a normal rate, but it's taking a lot of time to relax back to its original position. Okay, for the muscles, Have a look. Close it again and think about the laid. Relax, Asian. So how much can see? It's taking a lot of ticks some time for the muscle to come back to its original state. So I have ordered this video again. It's showing the same thing. So it's delayed. Relax, Asian get. So you see, if you look really closely, that's delayed. Relax. Asian. Okay, the normal reflexes normal. Okay, The contraction of muscles normal, but it's taking a while for the muscles to relax. Okay, Last one again. This is still the delay be reflex thing. Um, because these Okay, so this is at presentation and after treatment. So I have a watch. So you see, after treatment, it it relaxes at a normal rates. Okay, but at presentation, it's taking a long time for it to relax. Okay. So I will watch again. Guess that the contracting of the same grapes, okay, but it takes a long time to relax. Okay, so then again, check deep tendon reflexes. Okay? You only typically need to check the knee jerk reflex. Okay. And you think about hyperreflexic here for hypothyroidism and delay. The plaques is for hypothyroidism. Okay, cool. So that's, you know, legs. Okay, that's pretty much it. So we checked for protein pill myxedema. We checked for proximal my Optivar. Asking the patient to stand up from a chair with their arms cross. We tested the knee jerk reflex on. That's it. Okay, that's your exam. So thank the patient story clothing, and that's your thyroid examination. Okay, Those were different steps. So this is how you can finish off the examination. Okay. So different ways you can present your findings and intensity of investigations. Make sure to offer to do the heart function tests BCG. And you could do a thyroid ultrasound. Okay. Remember, clever practice. The thyroid examination is pretty useless. Okay? You don't pick up much from doing a thyroid examination. The most useful thing to do it the thyroid patients is to do thyroid function tests. Okay, but you still need to know the different steps about that example your skis. But, you know, you're different investigations and yeah, thank you guys for coming, um, again is long session. I'm sorry. The sessions along figure I do a trying very concise, like an but thank you guys for coming. Um, because enjoyed we pretty much.