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  <head>
    <title>026-02 Phenotype-led endocrine testing and reproductive diagnostic safety</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Phenotype-led endocrine testing and reproductive safety">
      <outline text="Build the phenotype before ordering">
        <outline text="Common symptoms have low specificity">
          <outline text="Value rises with coherent cluster, signs, time course"/>
        </outline>
        <outline text="Define axis and suspected mechanism">
          <outline text="Excess, deficiency, resistance, compression"/>
          <outline text="Target, controller, timing, distorting factor"/>
        </outline>
        <outline text="Broad panels create incidental, contradictory results"/>
        <outline text="Medication history must include route">
          <outline text="Inhaled, injected, ocular steroids suppress adrenal axis"/>
          <outline text="Supplements: biotin, iodine, undeclared hormones"/>
          <outline text="Opioids lower gonadal drive, dopamine blockers raise prolactin"/>
        </outline>
      </outline>
      <outline text="Examination tests the mechanism">
        <outline text="True proximal weakness is shoulder or hip power">
          <outline text="Needs localisation: bulk, reflexes, sensation, gait"/>
        </outline>
        <outline text="Skin specificity comes from morphology">
          <outline text="Broad violaceous striae with bruising and weakness"/>
          <outline text="Diffuse crease and mucosal pigment: adrenocorticotropic drive"/>
          <outline text="Velvety flexural pigment suggests insulin resistance"/>
        </outline>
        <outline text="Thyroid eye: more than prominence">
          <outline text="Colour desaturation, pupillary defect, corneal injury"/>
          <outline text="Optic nerve or cornea at risk: urgent review"/>
        </outline>
        <outline text="Palpation cannot settle thyroid function">
          <outline text="Normal gland may be dysfunctional, large may be euthyroid"/>
        </outline>
      </outline>
      <outline text="Pair hormone and regulator">
        <outline text="Thyroid-stimulating hormone and thyroxine: primary or central"/>
        <outline text="Calcium with parathyroid hormone: appropriate response"/>
        <outline text="Gonadal steroid with luteinising and follicle-stimulating"/>
        <outline text="Judge regulator against physiological demand">
          <outline text="Normal parathyroid hormone in hypercalcaemia: inappropriate"/>
          <outline text="Normal thyroid-stimulating hormone despite low thyroxine"/>
        </outline>
        <outline text="Sample pairs under the same conditions">
          <outline text="Discordance: repeat and discuss before rare diagnoses"/>
        </outline>
      </outline>
      <outline text="Dynamic tests and pre-test probability">
        <outline text="Stimulation when baseline indeterminate, reserve matters"/>
        <outline text="Suppression when autonomy suspected"/>
        <outline text="Performance falls outside validated populations"/>
        <outline text="Cortisol: steroids, oestrogen, binding proteins, sleep">
          <outline text="Dexamethasone fails: absorption, induction, adherence"/>
          <outline text="Abnormal screen gives neither source nor image target"/>
        </outline>
        <outline text="Aldosterone-renin: posture, sodium, potassium">
          <outline text="Hypokalaemia suppresses aldosterone: false negative"/>
        </outline>
        <outline text="Water testing can shift sodium dangerously">
          <outline text="Baseline osmolality and output often narrow diagnosis"/>
        </outline>
      </outline>
      <outline text="Reproductive history as temporal physiology">
        <outline text="Cycle interval, duration, volume, change from baseline"/>
        <outline text="Irregular cycles: inconsistent ovulation, cause unknown"/>
        <outline text="Quantify heavy bleeding objectively">
          <outline text="Flooding, clots, night protection, missed activity"/>
        </outline>
        <outline text="Sexual history separates each phase of function">
          <outline text="Neutral questions still require asking about coercion"/>
        </outline>
      </outline>
      <outline text="Intimate examination as consent process">
        <outline text="Consent is ongoing, not one-time">
          <outline text="Reconfirm before external to internal step"/>
        </outline>
        <outline text="Trauma-informed: control over position and support"/>
        <outline text="Silence is not consent">
          <outline text="Distress or withdrawal: pause and reassess"/>
        </outline>
        <outline text="Bimanual has limited sensitivity">
          <outline text="Normal result excludes neither ectopic nor torsion"/>
        </outline>
        <outline text="Sudden testicular pain is time-critical">
          <outline text="Strong torsion picture: urgent surgical assessment"/>
        </outline>
        <outline text="Hard painless mass: malignant until assessed"/>
      </outline>
      <outline text="Early pregnancy and uncertainty">
        <outline text="Location may not be settled at one visit">
          <outline text="Integrate trends, ultrasound, dates, symptoms, haemodynamics"/>
        </outline>
        <outline text="High value without sac raises concern, not proof"/>
        <outline text="Pregnancy of unknown location is temporary">
          <outline text="Early intrauterine, failing, or ectopic"/>
          <outline text="Clear return advice and ownership of repeat tests"/>
        </outline>
        <outline text="Instability or peritonism: resuscitate, not serial tests"/>
      </outline>
      <outline text="Infertility as a paired assessment">
        <outline text="Both partners in parallel">
          <outline text="One-partner testing delays care, misplaces blame"/>
        </outline>
        <outline text="Progesterone timed to ovulation, not calendar"/>
        <outline text="Reserve tests do not predict natural conception"/>
        <outline text="Each test answers a limited question">
          <outline text="Tubal patency shows passage, not all function"/>
          <outline text="Laparoscopy carries procedural risk"/>
        </outline>
      </outline>
      <outline text="Diabetes surveillance and final report">
        <outline text="Close actionable loops">
          <outline text="Foot risk sets education, footwear, referral"/>
          <outline text="Injection sites prompt technique change"/>
        </outline>
        <outline text="Autonomic clues: orthostasis, bladder, sweating"/>
        <outline text="Schedule eye, kidney, heart, mental-health surveillance"/>
        <outline text="Review time below range and alert usefulness"/>
        <outline text="Report separates phenotype, localisation, uncertainty">
          <outline text="Name danger and ownership of follow-up"/>
        </outline>
      </outline>
    </outline>
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