BEDSIDE CLINICS 9TH EDITION

406 Bedside Clinics in Medicine
Use of beta-blockers in internal medicine :
Remember the indications from head to foot as,
1. Anxiety states.
2. Migraine (as prophylaxis).
3. Glaucoma (chronic open-angle).
4. Thyrotoxicosis.
5. Prevention of vartceal haemorrhage (i.e., portal hypertension).
6. Cardiovascular system— Systemic hypertension, angina pectoris (stable and unstable), myocardial
infarction, cardiac arrhythmias (specially tachyarrhythmias), hypertrophic obstructive
cardiomyopathy (HOCM), mitral valve prolapse syndrome (MVPS), dissection of aorta, cyanotic
spells of Fallot’s tetralogy.
7. Essential tremor.
8. Pheochromocytoma.
9. Alcohol withdrawal syndrome.
Thyroid storm or thyrotoxic crisis :
It is an extreme degree of hyperthyroid state precipitated by surgery, infection, severe stress, or
develops spontaneously in patients with hyperthyroidism. The patients usually suffer from restlessness,
delusions, hyperpyrexia, delirium, tachyarrhythmias, hypotension, vomiting, diarrhoea and often
coma, and may succumb from heart failure, arrhythmias and hyperpyrexia..
Identification points (thyrotoxicosis) :
1. Goitre with exophthalmos is the first clue—the patient looks anxious, restless and fidgety.
2. Nov/ examine for tremor and tachycardia.
3. Never forget to examine the jerks.
* If thyrotoxicosis is given as a long case, examine the patient in the following way :
(A) General survey (specially nutrition, facies, neck glands, pulse, BP, skin and appendages).
(B) Examination of the thyroid gland and eye.
(C) Systemic examination :
a) CVS,
b) Nervous system,
c) G.I. system,
d) Respiratory system, and
e) Reticulo-endothelial system.
' ' Hyperthyroidism indicates glandular hypertrophy of thyroid; thyrotoxicosis is increased circulating
free thyroid hormones along with toxic features.
*** Heat intolerance is a common general symptom of hyperthyroidism.
Lndocrinal emergencies in clinical practice are thyroid storm, myxoedema coma, pituitarv apoplexy,
ectopic ACTH syndrome, Nelson’s syndrome. Read the section on ‘Diabetes mellitus’ for diabetic
emergencies.
Case 71
Exophthalmos
What is exophthalmos ?
It is the forward protrusion of the eyeball when a portion of the sclera is visible above and below
the cornea. Previously, it was defined as the visibility of the lower sclera of more than 2 mm when the
patient looks straight forward (few clinicians still believe this definition).
In exophthalmos (unilateral), the globes appear asymmetric.
How the exophthalmos is tested at the bedside ? -
1. The patient is asked to look straight forward. The examiner stands in front of the patient
and the visibility of the upper and lower sclera is noted. The visibility of the lower sclera