Acromegaly physical examination: Difference between revisions

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==Overview==
==Overview==
*Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with acromegaly usually appear tired. Physical examination of patients with acromegaly is usually remarkable for [[skin tags]], [[acanthosis nigricans]], and [[hyperhidrosis]]. Common findings in physical examination include [[frontal]] bossing, [[headache]], [[macroglossia]], and [[prognathism]]. Cardiovascular findings include [[ventricular hypertrophy]], [[heart failure]], and [[arrhythmias]]. Skeletal findings include joint effusion, [[osteopenia]], [[kyphoscoliosis]], [[muscle weakness]], [[paraesthesia]], and [[malocclusion]] of the mouth leading [[temporomandibular joint]] tenderness.
*Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
==Physical Examination==
==Physical Examination==
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].
*Patients with acromegaly usually appear tired
*Patient is usually oriented to persons, place, and time


===Vital Signs===
===Vital Signs===
 
*[[Hypertension]]
*High-grade / low-grade fever
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
*Thickening of the skin   
*Thickening of the [[skin]]  
*Skin tags   
*[[Skin tags]]  
*Acanthosis nigricans   
*[[Acne]]
*Hyperhidrosis   
*[[Acanthosis nigricans]]  
*[[Hyperhidrosis]]  


<gallery widths="150px">
<gallery widths="200px">


UploadedImage-01.jpg | Description {{dermref}}
Acanthosis-nigricans4.jpg | Description {{Acanthosis nigricans in the axilla}}
UploadedImage-02.jpg | Description {{dermref}}


</gallery>
</gallery>


===HEENT===
===HEENT===
* Abnormalities of the head/hair may include ___
* Abnormalities of the head include frontal bossing
* Evidence of trauma
* Acral enlargement
* Icteric sclera
* Visual deficits
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
* [[Headache]]  
 
* [[Macroglossia]]  
===Neck===
* [[Prognathism]]
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Asymmetric chest expansion / Decreased chest expansion
*Obstruction of the upper airways
*Lungs are hypo/hyperresonant
*[[Obstructive sleep apnea]]  
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
===Heart===
*Chest tenderness upon palpation
Cardiac manifestations in acromegaly patients include the following:<ref name="pmid9100571">{{cite journal| author=López-Velasco R, Escobar-Morreale HF, Vega B, Villa E, Sancho JM, Moya-Mur JL et al.| title=Cardiac involvement in acromegaly: specific myocardiopathy or consequence of systemic hypertension? | journal=J Clin Endocrinol Metab | year= 1997 | volume= 82 | issue= 4 | pages= 1047-53 | pmid=9100571 | doi=10.1210/jcem.82.4.3876 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9100571  }} </ref><ref name="pmid144034">{{cite journal |vauthors=Martins JB, Kerber RE, Sherman BM, Marcus ML, Ehrhardt JC |title=Cardiac size and function in acromegaly |journal=Circulation |volume=56 |issue=5 |pages=863–9 |year=1977 |pmid=144034 |doi= |url=}} </ref>
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Ventricular hypertrophy]]  
*[[Heave]] / [[thrill]]
*Diastolic heart failure (the most common cause of death)
*[[Friction rub]]
*Diastolic and systolic dysfunction
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Arrhythmias]]  
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Cardiomyopathy]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
 
===Abdomen===
*[[Abdominal distention]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
=== Abdomen ===
*Point tenderness over __ vertebrae (e.g. L3-L4)
* Colon diverticula
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Back===  
*A pelvic/adnexal mass may be palpated
*[[Vertebral fractures]]
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
*[[Osteopenia]]
* Altered mental status
*[[Osteoarthritis]]
* Glasgow coma scale is ___ / 15
*Joints effusion, [[swelling]], and [[crepitus]]
* Clonus may be present
*Acromegaly rosary: [[hypertrophy]] of the [[ribs]] and [[Costochondral joint|costochondral junction]] enlargement in the chest wall.<ref name="pmid1670798">{{cite journal| author=Ibbertson HK, Manning PJ, Holdaway IM, Gamble G, Synek BJ| title=The acromegalic rosary. | journal=Lancet | year= 1991 | volume= 337 | issue= 8734 | pages= 154-6 | pmid=1670798 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1670798  }} </ref>
* Hyperreflexia / hyporeflexia / areflexia
*[[Muscle weakness]]
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
*[[Joint stiffness]] in late cases
* Muscle rigidity
*[[Malocclusion]] of patient jaw associated with [[temporomandibular joint]] tenderness
* Proximal/distal muscle weakness unilaterally/bilaterally
*[[Kyphoscoliosis]]<ref name="pmid1521514">{{cite journal| author=Molitch ME| title=Clinical manifestations of acromegaly. | journal=Endocrinol Metab Clin North Am | year= 1992 | volume= 21 | issue= 3 | pages= 597-614 | pmid=1521514 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1521514  }} </ref>
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*[[Paraesthesia]]
*Unilateral/bilateral upper/lower extremity weakness
*[[Cranial nerve palsy|Cranial nerves palsy]]
*Unilateral/bilateral sensory loss in the upper/lower extremity
*[[Carpal tunnel syndrome]]
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Genitourinary===  
*[[Clubbing]]  
*In females:<ref name="IulianoLaws2014">{{cite journal|last1=Iuliano|first1=Sherry L.|last2=Laws|first2=Edward R.|title=Recognizing the clinical manifestations of acromegaly: Case studies|journal=Journal of the American Association of Nurse Practitioners|volume=26|issue=3|year=2014|pages=136–142|issn=23276886|doi=10.1002/2327-6924.12076}}</ref>
*[[Cyanosis]]  
**[[Amenorrhea]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
**[[Galactorrhea]]  
*Muscle atrophy
*In males:<ref name="IulianoLaws2014">{{cite journal|last1=Iuliano|first1=Sherry L.|last2=Laws|first2=Edward R.|title=Recognizing the clinical manifestations of acromegaly: Case studies|journal=Journal of the American Association of Nurse Practitioners|volume=26|issue=3|year=2014|pages=136–142|issn=23276886|doi=10.1002/2327-6924.12076}}</ref>
*Fasciculations in the upper/lower extremity
**[[Sexual dysfunction]]  
**[[Loss of libido]]
**[[Gynecomastia]]


==References==
==References==

Latest revision as of 21:58, 24 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Patients with acromegaly usually appear tired. Physical examination of patients with acromegaly is usually remarkable for skin tags, acanthosis nigricans, and hyperhidrosis. Common findings in physical examination include frontal bossing, headache, macroglossia, and prognathism. Cardiovascular findings include ventricular hypertrophy, heart failure, and arrhythmias. Skeletal findings include joint effusion, osteopenia, kyphoscoliosis, muscle weakness, paraesthesia, and malocclusion of the mouth leading temporomandibular joint tenderness.

Physical Examination

Appearance of the Patient

  • Patients with acromegaly usually appear tired
  • Patient is usually oriented to persons, place, and time

Vital Signs

Skin

HEENT

  • Abnormalities of the head include frontal bossing
  • Acral enlargement
  • Visual deficits
  • Hearing acuity may be reduced
  • Facial tenderness
  • Headache
  • Macroglossia
  • Prognathism

Lungs

Heart

Cardiac manifestations in acromegaly patients include the following:[1][2]

Abdomen

  • Colon diverticula

Back

Neuromuscular

Genitourinary

References

  1. ↑ López-Velasco R, Escobar-Morreale HF, Vega B, Villa E, Sancho JM, Moya-Mur JL; et al. (1997). "Cardiac involvement in acromegaly: specific myocardiopathy or consequence of systemic hypertension?". J Clin Endocrinol Metab. 82 (4): 1047–53. doi:10.1210/jcem.82.4.3876. PMID 9100571.
  2. ↑ Martins JB, Kerber RE, Sherman BM, Marcus ML, Ehrhardt JC (1977). "Cardiac size and function in acromegaly". Circulation. 56 (5): 863–9. PMID 144034.
  3. ↑ Ibbertson HK, Manning PJ, Holdaway IM, Gamble G, Synek BJ (1991). "The acromegalic rosary". Lancet. 337 (8734): 154–6. PMID 1670798.
  4. ↑ Molitch ME (1992). "Clinical manifestations of acromegaly". Endocrinol Metab Clin North Am. 21 (3): 597–614. PMID 1521514.
  5. ↑ 5.0 5.1 Iuliano, Sherry L.; Laws, Edward R. (2014). "Recognizing the clinical manifestations of acromegaly: Case studies". Journal of the American Association of Nurse Practitioners. 26 (3): 136–142. doi:10.1002/2327-6924.12076. ISSN 2327-6886.

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