Diagnosis and symptoms of diseases of the endocrine system. Course work: methods of studying the endocrine system in normal and pathological conditions

8.Functional and diagnostic methods of research for diseases of the endocrine system.ppt

• Number of slides: 29

To make this lecture easier to understand, let us recall some brief anatomical and physiological data on the endocrine system. n The endocrine system is the system that releases hormones into the blood. “Hormones” are chemical substances secreted into the blood or lymphatic vessels and having various effects on target organs. n Back in the middle of the twentieth century, it mainly included clearly organized morphological formations called glands. n n. By now this concept has become much broader. It turned out that many other organs and tissues have endocrine functions.

n For example, one of these places turned out to be the hypothalamus. n It turned out that the hypothalamus secretes: thyroliberin, luliberin, corticoliberin, prolactoliberin, folliculoliberin, somatoliberin, melanocytoliberin, luteostatin, melanocytostatin, which regulate the functioning of the pituitary gland

n The liver secretes angiotensin. Kidneys – erythropotin and renin. Stomach – gastrin, somatostatin. n 12 duodenal and small intestines - motilin, secretin, cholecystokinin pancreozymin, somatostatin. Cardiac atria and brain - atrial and brain natriuric peptides, respectively. Connective tissue and cells of mesenchymal origin are somatomedins. n Adipose tissue – leptin, adiponectin, etc.

n. In our subject it is not possible to analyze in detail all these hormones and their actions. But this information must be remembered once and for all: the endocrine system is not only the endocrine glands. However, here and today we are forced to talk specifically about the endocrine glands and their functions.

n The system of endocrine glands is scattered throughout the body (Fig.) 1. Pituitary gland. 2. Thyroid gland. 3; 4 and 7. Adrenal glands. 5. Sex glands. 6. Pancreas. 8. Thymus (thymus gland) 9. Parathyroid glands. 10. Epiphysis. Let's briefly look at their morphology and functions.

n. The pineal gland secretes the hormone melatonin, which activates the division of pigment cells in the skin and has an antigonadotropic effect. n. The pituitary gland consists of the anterior adenohypophysis and the posterior - neurohypophysis and intermediate parts (lobes). The anterior lobe of the pituitary gland produces somatotropin - growth hormone; gonadotropic hormones that stimulate male and female sex glands; lactogenic hormone that supports the secretion of estrogen and progesterone by the ovaries; ACTH, which stimulates the production of adrenal hormones; TSH, which regulates the functioning of the thyroid gland. The posterior lobe of the pituitary gland contains two hormones: oxytocin, which regulates labor and secretion of the mammary glands, and vasopressin or antidiuretic hormone, which mainly regulates the reabsorption of water from the renal tubules. The intermediate part is the hormone intermedin, which regulates pigment metabolism in the integumentary tissues. .

THE THIROID GLAND produces thyroxine (T 4) and triiodothyronine (T 3), which regulate general metabolism in the body, influence the formation of the skeleton, accelerate bone growth and ossification of epiphyseal cartilage; calcitonin, which regulates the metabolism of calcium and phosphorus. Its functions are studied by determining these hormones.

The parathyroid glands regulate the metabolism of calcium and phosphorus. Removing the parathyroid glands causes seizures and can lead to death. n Thymus (the thymus gland is the most important organ of the body’s immunological defense. It ensures the differentiation and proliferation of bone marrow stem cells; produces the enzyme thymosin, which ensures the immunological competence of lymphocytes throughout the body. T lymphocytes formed in the bone marrow enter the thymus and, under the influence of thymosin, become differentiated and immunologically competent and become the main mediators of cellular immunity n n

n The adrenal glands consist of two layers - the cortex and the medulla. n The medulla produces two hormones that mediate the sympathetic nervous system - adrenaline and norepinephrine. They increase the contractility and excitability of the heart, constrict skin blood vessels, and increase blood pressure. . n The cortex is an extremely important formation of the human body. It produces about 30 different hormones that regulate the concentration of sodium, potassium and chlorine in the blood and tissues, carbohydrate, protein and fat metabolism, as well as the production of sex hormones

The pancreas is an organ that has both exocrine and endocrine functions. The exocrine function was discussed in the section on diseases of the digestive system. Endocrine function is provided by special cells collected in small islands (islets of Langerhans), which are embedded in the gland tissue throughout its entire volume. They produce the hormone insulin. Insulin mainly regulates carbohydrate metabolism - the consumption of glucose by various systems of the body, ensuring the transfer

Let us now consider the issues of the norm of hormones secreted by these glands. Here, unfortunately, we must immediately make a reservation that in various sources in Russia you can find significantly different normal values ​​of these hormones, which depends on the lack of standardization of research methods and on the chaos that exists today place in this country. Even if there were uniform standards in Russia, no one is going to adhere to them - everyone uses the method that is easier for them to implement or that they like best. However, we must outline approximate standards for you, and you should know them. n As mentioned above, the anterior lobe of the pituitary gland secretes a significant amount of a wide variety of hormones.

The fasting GH level is 8 ng/ml. As is known, overproduction of this hormone can be observed with gigantism or acromegaly, and underproduction can be observed with pituitary dwarfism, which we discussed in the lecture “Question, examination... for endocrine diseases” n TSH is 0.45 - 6.2 microns. IU/ml. Thyroid-stimulating hormone regulates the function of the thyroid gland, and its overproduction can lead to hyperthyroidism, and decreased production can lead to myxedema n

ACTH – (on an empty stomach, at 8 o’clock in the morning, in the supine position) -

The delusion gets me everywhere - the nonsense of newspapers, television, radio. Nonsense shelling: the flight is too short, But it always hits and wounds. It is impossible to interrupt this nonsense, You cannot shield yourself from it with earplugs... Those who create troubles from victories, And trade in lost souls, And others, in order to block the shouting, So that they can finally be heard, Show hysterical agility Even in church in prayers to the Almighty.

n The PL level in men is 2–12 ng/ml, in women 2–20 ng/ml. n The level of ADH in the blood is 29 ng/ml. n Targeted radiography of the “sella turcica” and especially nuclear magnetic resonance (NMR) studies and computed tomography are of great help in diagnosing diseases of the pituitary gland. n These methods make it possible to detect pituitary tumors up to 0.2 cm in diameter (microadenomas) with 97% confidence.

Pancreas The main methods for studying the endocrine function of the pancreas are the direct determination of the level of insulin and glucagon in the blood. However, these methods have not yet entered into widespread practice. The most widely used methods for indirectly studying the insulin-producing function of the pancreas are determination of glucose in the blood and urine and a glucose tolerance test.

n Determination of glucose in the blood is carried out on an empty stomach. The normal level is fluctuating from 3.33 to 5.5 (according to some methods up to 6.105) mmol/l. n An increase in blood glucose levels is called n This indicator is almost hyperglycemia. a reliable sign of the presence of diabetes mellitus in a person (it should be remembered that hyperglycemia can also have other origins). n There may also be a decrease in blood glucose levels, which is called hypoglycemia. This condition can occur both with diabetes mellitus and with a number of diseases, which may be based on tumors or damage to the endocrine glands of another order.

n Determination of glucose (sugar) in urine is usually carried out in a daily volume of urine. Normally, there is no glucose in the urine. Its appearance is called glycosuria and is a serious sign of diabetes mellitus, although sometimes it can occur after heavy consumption of sweet foods and a rare disease - renal diabetes. n Glucose tolerance test. In many people, diabetes occurs hidden, latently (the so-called impaired glucose tolerance). These people may have minor stigmata of diabetes that are not confirmed by routine urine and blood tests. To clarify the diagnosis in these cases, this test was developed.

Typically, the test is performed as follows: the subject is taken to test blood for glucose on an empty stomach, then given 75 g (or, more precisely, 50 g per m 2 body area) of glucose dissolved in 100-200 ml of water to drink, and the blood is tested for glucose every 30 minutes at over the next 3 hours. n Interpretation of the results: in a healthy person, the rise in glucose levels after 1 hour does not exceed 80% of the initial level, by 2 hours it drops to normal and by 2.5 hours it may fall below normal. n In patients, the maximum rise is observed after 1 hour, reaches figures above 80% of the initial value, and normalization is delayed for 3 hours or more. n

n n n Thyroid gland Methods for studying the functions and clinical morphology of the thyroid gland include determination of protein-bound iodine, the level of thyroid hormones, the shape and size of the gland. Determination of protein-bound iodine (PBI) is one of the most important and accurate methods for studying gland function. SBI consists of 90-95% of the thyroid hormone thyroxine. Normally, SBI is 315, 18,630, 37 nmol/l. With thyrotoxicosis, its level is above 630.37 nmol/l, with hypothyroidism it is less than 315.18 nmol/l.

n Thyroxine (T 4) and triiodothyronine (T 3) are determined from the thyroid hormones. Approximate norms: T 4 60 160 nmol / l, and T 3 1, 2 2, 8 nmol / l. At the same time, as a rule, the TSH level is determined, which, according to the same methods, is normally 0.17 4.05 nmol/l. n One of the objective methods for studying the morphology and function of the thyroid gland is scanning using radioactive isotopes. The scanograms can outline the size of the thyroid gland, areas of hypo- and hyperfunction. n n

n. In recent years, ultrasound examination (ultrasound) has been widely used to examine the thyroid gland. Ultrasound is currently the method of choice in determining the size of the thyroid gland and the presence of changes in its structure. n A highly effective research method is CT, which allows you to study the size and structure, identify tumors or other changes in it.

Adrenal glands (cortical layer) To study the function of the adrenal cortex, aldosterone is determined in the urine, 17 hydroxycorticosteroids (17 OX) in the blood and urine, and 17 neutral ketosteroids (17 KS) in the urine. n Determination of aldosterone. It is believed that there is a directly proportional relationship between the amount of aldosterone in the urine and the mineralocorticoid activity of the adrenal cortex. n Healthy people secrete from 8.34 to 41.7 nmol/day. aldosterone. n Increased urinary aldosterone excretion can be observed in so-called primary and secondary hyperaldosteronism (adenoma or tumor or cortical hyperfunction). n

Definition 17 OCS reflects the level of glucocorticosteroids in the blood. n Normally, 17 OCS in the blood contains from 0.14 to 0.55 µmol/l. n A persistent increase in 17-ox levels is observed in adrenal tumors and Cushing's syndrome. n A decrease in 17 OCS is found with hypofunction of the adrenal cortex or insufficiency of the anterior pituitary gland. n n Excretion of 17-OX in urine normally parallels changes in the blood. Determination of cortisol in urine is considered even more specific for studying glucocorticosteroid function of the adrenal glands. n Normal 55,248 nmol/day. n

n Definition 17 CC. Most of the 17 CS come from androgens, so their determination allows us to make a judgment about the androgenic function of the adrenal cortex. Normally, 27.7 79.7 µmol/day is excreted in men and 17.4 55.4 in women. n A decrease in the release of 17 KS is typical for adrenal insufficiency, an increase for tumors. n There are also methods for indirectly determining the functions of the adrenal cortex. These include the determination of sodium and potassium in blood and urine. n

It is known that in the regulation of electrolyte levels (especially sodium and potassium), the main role belongs to mineralocorticoids, in particular aldosterone, and to a lesser extent glucocorticoids. n In this regard, the level of sodium and potassium in the blood and their excretion in the urine will indirectly indicate the state of production of these hormones by the adrenal glands. Normally, sodium in the blood plasma contains 135-145 mmol/l, and potassium 3.8-4.6 mmol/l. n Normally, 122,260 mmol/day is excreted in urine. sodium and 25 100 mmol/day. potassium n In practice, determination in urine is rarely performed. n

Adrenal glands (medulla) Studying the function of the adrenal medulla is most often resorted to when a tumor is suspected. n 3 hormones are studied - adrenaline, norepinephrine, dopamine in the blood or plasma. n Their level in plasma is equal to - adrenaline

Endocrine diseases are all kinds of hormonal disorders that most often arise due to dysfunction of the thyroid and pancreas, as well as as a result of systemic diseases. Type 2 diabetes mellitus is one of endocrine diseases, the number of cases of which has been steadily growing in recent years and is becoming truly threatening. All diseases of the endocrine system cause complex disorders in the body, reducing the quality of life and destroying human health.

Routine examinations of the endocrine system:
Since the likelihood of developing diabetes mellitus increases over the years, the frequency and necessity of control tests depends on age.
Up to 45 years of age, a blood test for glucose is done if there is any suspicion of hormonal disorders (as directed by a doctor).
After 45 years of age, a blood glucose test should be done at least once every three years.
At any age, if you are at risk for diabetes, you need to do it regularly.

More information about diseases and risk factors of the endocrine system -.

Blood glucose test

Target. The level of glucose (sugar) in the blood shows how correctly carbohydrate metabolism occurs in the body with the participation of the hormone insulin. Exceeding the normal glucose level indicates hyperglycemia (one of the indicators of type 2 diabetes), falling below normal indicates hypoglycemia (indicative of a lack of energy).

Way. In the classic case, blood is taken for glucose on an empty stomach: at least 8-10 hours must pass between the last (evening) meal and blood sampling. Also during this period you should not drink sweet drinks, alcohol, you can only drink water and weak unsweetened tea. Also, as prescribed by the doctor, blood is taken for glucose under load: in this case, a control blood sample is first taken on an empty stomach, then the person drinks a sweet solution, and his blood is taken again - several times over two hours. This allows you to track the dynamics of the increase and regulation of blood sugar levels.

conclusions. Normal blood sugar levels are 3.3 - 5.5 mmol/l. The closer your indicator is to the upper limit, the more alarming the result. An increased level of glucose in the blood signals not only the possibility of developing diabetes mellitus, but also a number of other disorders, for example, pancreatitis, cystic fibrosis, and pancreatic dysfunction. Even severe stress can cause blood glucose levels to rise.

Blood test for hormones

Target. A characteristic feature of the hormones produced by the thyroid, pancreas, reproductive system, adrenal glands, and pituitary gland is their overall effect on the body. Therefore, if any hormonal imbalance occurs, the consequences can be very diverse - from the development of diabetes to problems with reproductive function, skin, etc. Hormone analysis allows you to determine the level of various hormones in the blood, compare it with the norm and draw appropriate conclusions.

Way. Blood for hormones is donated on an empty stomach from a vein: 10 hours before blood sampling, you should not eat or drink, and you should also refrain from physical activity and vigorous activity at work. If you are taking any medications, especially hormonal ones, consult your doctor and decide on a temporary withdrawal regimen so as not to harm yourself and to get reliable test results.

conclusions. The result of a blood test for hormones is a list of hormones (testosterone, estrogen, progesterone, prolactin, luteinizing hormone, thyroid hormones, etc.) and their levels in your blood. If one of the values ​​does not fit into the norm, we can talk about a violation. But only a doctor can draw conclusions, because not only individual values ​​are important, but also their combination.

Ultrasound of the thyroid gland and adrenal glands

Target. Ultrasound of the endocrine glands - the thyroid gland and adrenal glands - allows us to identify disorders in the health of the organs themselves, which led to hormonal imbalance. An ultrasound is performed to determine the causes of hormonal disorders, as well as in cases where there are suspicions of changes in the glands (nodules in the thyroid gland).

Way. Ultrasound is performed using an ultrasound machine: a specialist places a sensor in the area of ​​the thyroid gland or adrenal glands and, receiving a picture on the monitor, can visually assess the condition of the organ and the nature of the disorders. The shape, size of the glands, the presence of deviations and deformations, as well as neoplasms are assessed. The lymph nodes and circulatory system are also considered.

conclusions. The result of the analysis is an ultrasound image and its visual interpretation relative to the norm. As a rule, ultrasound of the endocrine glands allows one to detect with a high degree of accuracy the presence of neoplasms in organs and visible changes in their structure. The image analysis is carried out exclusively by a doctor.

The state of the endocrine system can be judged indirectly by examination of the skin, subcutaneous fat, physical development, somatometry, since most endocrine glands are not accessible for direct examination, with the exception of the thyroid gland, testicles in boys and the thymus gland in infants. its increase.

Palpation of the thyroid gland is carried out with bent fingers, which are placed deeply behind the outer edges of the sternocleidomastial muscles and gradually penetrate the posterolateral surface of the lateral lobes of the thyroid gland. The thumbs are placed on the anterior surface of the lateral lobes of the gland. When swallowing, the gland moves upward, and its sliding at this time along the surface of the fingers greatly facilitates palpation examination. The isthmus of the thyroid gland is examined using sliding movements of the fingers along its surface in the direction from top to bottom, towards the manubrium of the sternum. When palpating the thyroid gland, it is necessary to note its size, surface features, the nature of the enlargement (diffuse, nodular, diffuse-nodular), the consistency of its softened parts, mobility (displaceability when swallowing), pulsation.

Palpation of the testicles: it is necessary to note whether the testicles are descended or not descended into the scrotum, note the shape, consistency, presence of seals, dropsy, etc., the length and diameter of the testicles.

An enlarged thymus gland can be identified by percussion. Percussion is quiet, direct, similar to the definition of the symptom of the Philosopher's cup (see respiratory organs). The presence of dullness outside the sternum is suspicious for enlarged thymus gland.

The study of the endocrine system also includes symptoms of increased mechanical excitability of muscles (with spasmophilia). For this purpose, determine:

1. Chvostek's sign - tapping the fossa canina with a percussion hammer leads to contraction of the muscles of the eyelid, and sometimes the upper lip.

2. Trousseau's sign - when applying a tourniquet or squeezing the middle of the shoulder with a hand, the child's hand takes the shape of the obstetrician's hand (carpopedal spasm).

3. Lyust's symptom - when tapping with a hammer behind the head of the fibula or when squeezing the calf muscle between the middle and lower third, we obtain abduction of the foot.

Additional research methods The value of additional examination methods: Laboratory Functional X-ray Radioisotope, ultrasound Other (invasive) Plan for a rational examination of patients with the most common diseases

Endocrine glands and their hormones Hypothalamus Releasing hormones Vasopressin and Oxytocin, which are synthesized in the hypothalamus and deposited in the neurohypophysis (posterior lobe) Pituitary gland Corticotropin (ACTH) Somatotropin (STH) Thyrotropin (TSH) Follitropin (FSH) Lutropin (LH luteinizing hormone) Prolactin ( PRL lactotropic hormone) Melanotropin (melanocyte-stimulating hormone)

Structure of endocrine function (V.B. Rosen, 1980) Biosynthesis and secretion of hormones in the gland Regulation and self-regulation of gland function Transport of secreted hormones in the blood Metabolism of hormones in the periphery, their excretion Interaction of hormones with reacting tissues NB! Disruption of any component of endocrine function can lead to its disruption and the development of disease

Endocrinopathies Itsenko-Cushing's disease Gigantism Acromegaly Pituitary dwarfism Obesity Diabetes mellitus DTG Endemic goiter Thyroiditis Toxic adenoma and thyroid cancer Acute and chronic adrenal insufficiency Pheochromocytoma Hyperparathyroidism Hypoparathyroidism Diabetes insipidus Menopausal syndrome

Complaints Weakness: general (its extreme manifestation is adynamia) - a symptom of hypocortisolism; muscular – diabetes, hyperthyroidism, hypothyroidism, hypercortisolism; Changes in the function of the nervous system: irritability, tearfulness, rapid mood swings (tachypsia) - thyrotoxicosis, hyperestrogenism, pathological menopause; bradypsychism (drowsiness, sluggishness, memory loss) – hypothyroidism;

Complaints: Headache due to pituitary tumors, acromegaly, Itsenko-Cushing's disease, thyrotoxicosis, hypothyroidism; Leg pain, paresthesia, cramps with diabetes (neuropathy), hypercortisolism (osteoporosis or spondyloarthrosis); Palpitations, cardialgia, hypertension with pheochromocytoma, hypothyroidism, diabetes, hypercortisolism; hypotension due to adrenal insufficiency, hypothyroidism; Hair loss due to hypothyroidism;

Complaints: Thirst, polyuria, moderate in diabetes mellitus and high in diabetes insipidus; Skin itching with diabetes; Changes in appetite: anorexia - hypocortisolism, hypopituitarism, hypothyroidism, anorexia nervosa; increased – diabetes, hypercortisolism, thyrotoxicosis, hypothalamic obesity; Puberty disorders, infertility, dysmenorrhea, menorrhagia, impotence; Growth disorders.

Anamnesis Morbi Time and causes of disorders Development dynamics of the disease Results of the examination Efficacy of previous treatment Patient awareness Therapeutic consent Vitae Heredity Diseases (viral, Tbc, autoimmune, metabolic, tumors), trauma, surgery Stress Gynecological history

Inspection Growth disturbance Rapid growth - hyperfunction of the adenohypophysis, stunted growth - with hypothyroidism, hypopituitarism, proportions - tall stature and long limbs with hypogonadism; childish body proportions and short stature with pituitary dwarfism; feminization and masculinization; changes in the skull, hands and feet with pituitary adenoma (acromegaly) due to increased periosteal growth under the influence of somatotropin;

Examination of body weight; decreased body weight in thyrotoxicosis, diabetes, hypocortisolism; increased BW in hypothyroidism, diabetes, hypercortisolism; distribution of subcutaneous fat: uniform – with nutritional-constitutional obesity; dysplastic type with cerebral or hypothalamic obesity (excessive obesity of the trunk with less pronounced fullness of the limbs)

Inspection Skin color, moisture, turgor: bronze in open areas and in places of friction of clothing, folds with pigmentation of mucous membranes (hypocortisolism), marbling, pronounced vascular pattern, purplish-red color, moon-shaped face, stretch marks (hypercortisolism); dryness, peeling, decreased skin turgor, vasodilation (rubeosis), pyoderma, furunculosis, mycosis, itching, trophic ulcers, carotenemia, lipodystrophy, xanthomatosis, necrobiosis lipoidica in diabetes;

Inspection Skin derivatives: Dry brittle hair, hair loss on the head, in the area of ​​the outer parts of the eyebrows with hypothyroidism; Hair growth according to the male type, coarse hair on the body with hair loss on the head due to hypercortisolism; Sparse facial hair in men with hypogonadism; Hirsutism; Thickening of nails, subungual hyperkeratosis in diabetes.

Inspection The shape of the neck changes with enlargement of the thyroid gland. Diffuse uniform enlargement of the thyroid gland; S-m Marie - small symmetrical tremor of the fingers of outstretched arms; S-m “telegraph pole” - a pronounced trembling of the patient, felt when touching the chest.

Eye symptoms Kraus's sign - shiny eyes; Expansion of the palpebral fissure; S-Graefe: when the vision fixes an object slowly descending downwards, a section of the sclera between the upper eyelid and the edge of the iris is exposed; Kocher's S-m - the same when moving an object from bottom to top;

Eye symptoms S-m Delrymplya - the same when fixing an object with vision in a horizontal plane; Rosenbach's syndrome - tremor of the eyelids with eyes closed; Geoffroy's S - inability to form folds on the forehead; S-m Shtelvaga - rare blinking; Mobius disorder – convergence violation.

Palpation of the thyroid gland Moderately dense, painful with thyroiditis; Dense, unevenly enlarged, with unclear contours, with nodes, immobile in case of malignant formation; Elastic, with a smooth, even surface, movable in case of endemic goiter;

Percussion has limited value; it reveals neuromuscular excitability in hypoparathyroidism: tapping with a percussion hammer below the zygomatic process along the line connecting the tragus of the ear with the corner of the mouth causes contraction of the muscles of the corner of the mouth, the wings of the nose and the eye (see Khvostek 1), the wings of the nose and the corners of the mouth (from Khvostek 2), only the muscles of the corners of the mouth (from Khvostek 3); changes from other organs and systems

Examination program Laboratory methods for OA of blood, urine, feces, determination of microalbuminuria, glucosuric profile, glycemic profile, glycosylated hemoglobin, lipid profile, proteinogram, creatinine, urea, transaminases, electrolytes, urinary iodine excretion,

Laboratory methods of hormones in the blood (releasing factors, insulin, thyroxine, triiodothyronine, estrogens, progesterone, prolactin, testosterone, somatotropin, catecholamines, corticosterone), saliva (testosterone, cortisol, catecholamines) and urine (catecholamines), antibodies to thyroid cells , pancreas, B- and T-lymphocytes, immunoglobulins

Functional X-ray ECG Rheoencephalogram, electroencephalogram Drug functional tests Determination of basal metabolism Determination of electrical excitability of muscles in hypoparathyroidism X-ray of the skull, hand skeleton, pneumopelviography Angiography X-ray or magnetic resonance imaging

Ultrasound, radioisotope Other ultrasound of the adrenal glands, thyroid gland, abdominal organs, pelvis, kidneys Radioisotope scanning of the endocrine glands (thyroid and pancreas) Puncture biopsy of the thyroid gland CONSULTATIONS with an ophthalmologist, fundus neurologist

Plan for a rational examination of patients with thyroid pathology OA of blood, urine, feces, lipid profile, proteinogram, glucose, transaminases, determination of thyroxine, triiodothyronine, antibodies to thyroid cells, B- and T-lymphocytes, immunoglobulins in the blood ECG Computed tomography Ultrasound of the thyroid gland , radioisotope scanning of the thyroid gland Thyroid puncture Fundus of the eye, consultation with an ophthalmologist Consultation with a neurologist

Plan for a rational examination of patients with diabetes mellitus OA of blood, urine, feces, determination of microalbuminuria, glucosuric profile, glycemic profile, glycolyzed hemoglobin, lipid profile, proteinogram, creatinine, urea, transaminases, electrolytes, blood insulin, antibodies to pancreas cells ECG, rheoencephalogram ultrasound kidneys, abdominal organs Fundus Consultation with a neurologist

Recommended reading Balabolkin M.I. Diabetology. M: Medicine, 2000; 672 Bogdanovich V.L. Diabetes mellitus (treatment and prevention). N. Novgorod: Publishing house of NGMA, 1997; 196 Dedov I.I., Shestakova M.V., Maksimova M.A. Federal target program “Diabetes mellitus” (Methodological recommendations). M.Media Sphere, 2002; 88 Dreval A.V. Diagnosis of diseases (interview method). M.: “Medicine”, 1994;160 Endocrinology / Efimov A.S., Bondar P.N., Zelinsky B.A. Under. ed. A.S. Efimova. K.: Vishcha School, 1983; 328

Inspection. Examination in the study of endocrine patients is of great importance, and often at the first glance at the patient it is possible to recognize the disease either by the general appearance of the patient, or by individual signs of the disease (Graves' disease, myxedema, acromegaly, gigantism, pituitary dystrophy, Addison's disease).

When examining, you need to pay attention to the following signs.

1) Body growth, as well as the sizes and ratios of its individual parts: significant deviations in growth should direct the doctor’s thoughts to dysfunction of the cerebral appendage, thyroid, reproductive or thymus glands; preservation or violation of proportionality in certain parts of the body and the presence of other characteristic signs make it possible to clarify the pathogenesis of growth disorders; a disproportionate increase in the distal parts of the body (nose, lips, chin, hands, feet) will indicate hyperfunction of the anterior pituitary gland (acromegaly), etc.

2) Fatness of patients and features of fat deposition. Obesity is most often associated with decreased function of the thyroid, pituitary gland or gonads, emaciation with hyperthyroidism, damage to the cerebral appendage (Simmonds disease), and decreased function of the pancreas (diabetes). The distribution of fat in the subcutaneous tissue in typical cases often allows us to get closer to the pathogenetic diagnosis of endocrine obesity: predominant fat deposition in the pelvic girdle (lower abdomen, buttocks, thighs) and on the chest is characteristic of pituitary and sexual obesity, more or less uniform distribution of fat throughout the body will speak for thyroid obesity. Severe weight loss is observed with hyperthyroidism, with Addison's disease and especially with Simmonds' disease (pituitary cachexia).

3) Body hair. Due to the dependence of hair growth on hormonal influences, mainly the gonads, thyroid gland, adrenal cortex and cerebral appendage, the condition and nature of the hairline are important diagnostic signs for disorders of internal secretion, such as: female type of hair growth in eunuchoidism, increased hair growth in hyperthyroidism and acromegaly, hypertrichosis (hirsutism) with tumors of the adrenal cortex, hair loss with myxedema, etc.

4) Condition of the skin - tenderness and brightness in Graves' disease, roughness and pallor in myxedema, dark brown color in Addison's disease, etc.

5) Face, its expression and changes in the eyes.

Of the endocrine glands, only the thyroid gland and testicles are accessible to direct examination: reduction and enlargement of these organs can be easily detected by examination.

Palpation. By palpation, you can examine the same two endocrine glands - the thyroid and the male reproductive glands, determining their size, density, uniformity or unevenness of consistency (nodularity), soreness, etc. Through a special gynecological examination using bimanual palpation, you can also feel the female reproductive glands - ovaries.

Palpation of the skin in Graves' disease and myxedema is of great diagnostic importance: with the first, the skin is thin, soft, smooth, (velvety), moist and hot, with the second - thick, dense, rough, dry and cold.

Percussion. With the help of percussion, it is possible to determine the retrosternally (retrosternally) located struma (goiter), and this is, apparently, the only use of percussion in the study of endocrine glands.

Auscultation. Auscultation in the study of endocrine glands also finds only one application, namely in the study of an enlarged thyroid gland, when one can hear a systolic gurgling noise arising in its dilated arterial vessels.

Anthropometric measurements. Anthropometric measurements can serve to objectively confirm those noted during examination or to identify subtle endocrine-related differences in proportions and body structure. Thus, gender differences are reflected in women, compared to men, by relatively shorter limb lengths, smaller shoulder widths, and larger pelvic sizes. Further, excessive leg length is characteristic of eunuchoidism, and relatively short legs are characteristic of early puberty. Determinations of height and weight also provide useful numerical data for the assessment of endocrine influences and endocrine pathology.

Determination of basal metabolism. Determination of basal metabolism is of great diagnostic importance for a number of diseases of the endocrine glands, especially the thyroid. By basal metabolism we mean the minimum amount of energy, expressed in calories, that the body needs to maintain its basic vital functions, i.e. blood circulation, respiration and constant body temperature. Therefore, the determination of the basal metabolic rate is carried out with complete physical rest on an empty stomach (no earlier than 12 hours after the last meal). The principle of determining the basal metabolic rate is that, using special equipment, the values ​​of pulmonary ventilation are directly determined, i.e., the amount of exhaled air and its composition, over a known period of time (usually 10 minutes). Then, using special tables, the amount of absorbed oxygen and released carbon dioxide and their ratio (respiratory coefficient) are calculated, and then the required number of calories per hour per 1 kg of weight (normally about 1 calorie) or per 1 m2 of body surface (normally about 40 calories ). An increase in basal metabolism by more than 10-15% will indicate an undoubted pathological increase and is most often observed in hyperthyroidism or Graves' disease, in which an increase of 30-50-80-100% is a common occurrence. A decrease in basal metabolism by 15-30-50% against the norm is characteristic of hypothyroidism and myxedema, pituitary dystrophy and Simmonds' disease.

X-ray method. The X-ray method of examination easily makes it possible to determine changes in the bone skeleton and judge endocrine diseases from them. Thus, it is possible to recognize: 1) tumors of the pituitary gland by changes in the size and shape of the sella turcica (its widening and deepening, destruction of the edges); 2) acromegaly - by thickening of the bones and enlargement of the air cavities of the skull, by the large development of exostoses around the joints; 3) eunuchoidism - by insufficient ossification of bone sutures and delayed ossification of the epiphyseal zones; 4) hypergenitalism - by accelerated ossification of the epiphyses.

X-ray can also identify a retrosternally located enlarged thyroid gland (retrosternal goiter).

Laboratory research. Of the everyday laboratory tests used for diagnostic purposes in recognizing endocrine diseases, we most often have to deal with urine and blood tests.

Urine examination- its daily amount, specific gravity and sugar content in it - is essential in recognizing diabetes mellitus and diabetes insipidus.

Blood test can also play a known role in the recognition of certain endocrine diseases. For example, secondary anemia is often one of the symptoms of insufficiency of the thyroid gland (myxedema) or adrenal glands (Addison's disease). A certain degree of polyglobulia occurs in Graves' disease. A change in the leukocyte formula towards lymphocytosis is characteristic of dysfunction of the thyroid gland in one direction or another - irrespective (Graves' disease, myxedema). In other endocrine disorders, the blood picture also changes, but these changes have not yet been sufficiently studied.

Functional research methods. Functional diagnostics of the endocrine glands has not yet acquired practical significance. Of the various methods used for this purpose (see special manuals on endocrinology), the most complex ones are of greatest importance: 1) determination of basal metabolism to assess the functional state of the thyroid gland; 2) determination of the specific dynamic effect of food - to identify the functional capacity of the pituitary gland and 3) study of glycemic blood curves - to judge the function of the pancreas, adrenal glands and thyroid gland.

Endocrinopathic syndromes
The main endocrinopathic syndromes are based mainly on the phenomena of hyperfunction or hypofunction of one or another endocrine gland.

I. Thyroid syndromes.
1. Hyperthyroid syndrome(hyperthyroidism, hyperthyroidism) is manifested by an increase in the volume of the thyroid gland, goiter (its hyperplasia), increased heart rate - tachycardia and protrusion of the eyeballs - bulging eyes (increased tone of the sympathetic nervous system).

This triad of symptoms is characteristic of severe cases of hyperthyroidism, the so-called Graves' disease. In addition to them, very important symptoms of hyperthyroidism are weight loss, depending on increased metabolism, trembling, diarrhea, sweating, vasomotor phenomena and phenomena of increased neuropsychic excitability associated with overexcitability of the autonomic sympathetic and parasympathetic nervous systems.

2. Hypothyroid syndrome(hypothyroidism, hypothyroidism) is often characterized by a decrease in the volume of the thyroid gland, a slowdown in heart rate and sunken eyeballs, then a tendency towards obesity, constipation, dry skin, a decrease in general nervous and mental excitability and, finally, a peculiar change in the skin and subcutaneous tissue that appears infiltrated, doughy-dense consistency, as if swollen, but when pressure is applied to them, they do not leave pits; This is the so-called mucous edema, hence the name of severe cases of this pathology - myxoedema.

II. Parathyroid syndromes.
1. Hyperparathyroid syndrome(hyperparathyroidism, hyperparathyroidism) is rare, accompanied by pstercalcemia and clinically, due to the loss of significant amounts of calcium salts by the skeleton, is expressed by atrophy and fibrous degeneration of bones with the formation of cavities in them, with their curvatures and fractures and with subsequent deformation of the skeleton "(general osteitis fibrocystis - osteitis or osteodystrophia fibrosa cystica general is ata - Recklinghausen's disease.

2. Typoparathyroid syndrome(hypoparathyroidism, hypoparathyroidism) is observed much more often; Hypocalcemia plays a significant role in its pathogenesis (as well as a shift in the acid-base balance to the alkaline side - alkalosis and a disorder of protein metabolism). The clinical manifestation of this syndrome is increased excitability mainly of the motor apparatus of the nervous system (with a decrease in calcium in the blood to 7 mg% or lower) and a tendency to tetanic convulsions. These cramps most often develop in the upper limbs (the forearms are bent, the fingers are joined together in the “obstetrician’s hand” position), less often the cramps also affect the lower limbs or also spread to the face, gastrointestinal tract or larynx. Seizures last from a few minutes to 1-2 hours and are easily repeated. In the clinic, this syndrome is called Spasmophilia or tetany.

III. Pituitary syndromes.
Disruption of the complex functions of the pituitary gland entails the development of a number of pituitary or pituitary syndromes. We will present here only the more clinically important ones.

A. Hyperfunction of the pituitary gland, more precisely, its anterior lobe (hyperpituitarism) can lead to the development of three pituitary syndromes: the most famous and common acromegalic, the so-called Cushing syndrome, and diabetic.

1. Acromegaly is based on a tumor-like growth (adenoma) of eosinophilic cells of the anterior pituitary gland and overproduction of the growth hormone secreted by them. This syndrome is characterized by large sizes of the hands, feet and skull, brow ridges, cheekbones, nose and chin; At the same time, not only the bones, but also the soft parts, including the lips and tongue, increase.

If this hyperfunction of the pituitary gland appears in childhood, then a sharp increase in overall growth is observed, which ultimately more or less significantly exceeds the physiological norm - gigantism develops. Gigantism, therefore, is like acromegaly of childhood.

The opposite, rare syndrome associated with hypofunction of eosinophilic cells of the anterior pituitary gland is acromicria (micros - Greek - small), expressed in a decrease in the volume of the extremities, mainly the arms.

2. Cushing's syndrome is based on the proliferation (adenoma) of basophilic cells of the anterior lobe and the overproduction of endocrinotropic (stimulating the activity of other endocrine glands) pituitary hormones. The main symptoms of this syndrome are obesity of the face and trunk (but not limbs) with the formation of skin scars and hypertrichosis (stimulation of the adrenal cortex), arterial hypertension and hyperglycemia (stimulation of the adrenal medulla), bone loss - osteoporosis (stimulation of the parathyroid glands).

3. Pituitary diabetes mellitus is associated with overproduction of a hormone that regulates carbohydrate metabolism and has an effect on it that is opposite to the action of insulin. This form of diabetes often accompanies acromegaly.

B. Hypofunction of the pituitary gland(hypopituitarism) underlies the following four syndromes:

1) pituitary obesity;

2) pituitary cachexia;

3) pituitary dwarf growth;

4) diabetes insipidus.

We took the described endocrinopathic syndromes in their isolated form. But, as already mentioned above, individual glands are parts of a single endocrine system. Therefore, in essence, there are no isolated dysfunctions of the gland alone. Inevitably, a number of other glands more closely related to the first are also involved in the process. Consequently, almost every endocrine disease has the character of multiple lesions of the glands - pluriglandular in nature. However, pluriglandular syndromes in the strict sense of the word are also distinguished, and these include those intrasecretory disorders in the pathogenesis of which it is not possible to identify the leading role of damage to one or another gland, such as infantilism, premature aging, endocrine depletion.

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