Secondary adrenal insufficiency physical examination: Difference between revisions

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__NOTOC__
__NOTOC__
{{Adrenal insufficiency}}
{{Secondary adrenal insufficiency}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{ADS}} {{IQ}}  


==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 secondary [[adrenal insufficiency]] usually appear [[weak]] or [[cushingoid]] (if the cause is [[glucocorticoid]] withdrawal). Physical examination of patients with secondary [[adrenal insufficiency]] is usually remarkable for [[cushingoid]] features like [[muscle weakness]], buffalo hump. [[Hypotension]] may or may not be present. The absence of [[hyperpigmentation]] is the hallmark and a distinguishing feature of secondary [[adrenal insufficiency]]. Also, the presence of [[visual field]] defects like [[bitemporal hemianopsia]] indicates a [[pituitary tumor]].


OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
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 secondary [[adrenal insufficiency]] usually appear [[weak]] and [[Fatigue|fatigued]].
*They may present with [[Cushingoid appearance|cushingoid features]] if there is any history of prolonged [[steroid]] intake.


===Vital Signs===
===Vital Signs===
 
*Low-grade [[fever]] may be present
*High-grade / low-grade fever
*[[Tachycardia]] may be present
*[[Hypothermia]] / hyperthermia may be present
*[[Hypotension]]-less common <ref name="pmid3002680">{{cite journal |vauthors=Burke CW |title=Adrenocortical insufficiency |journal=Clin Endocrinol Metab |volume=14 |issue=4 |pages=947–76 |year=1985 |pmid=3002680 |doi= |url=}}</ref><ref name="pmid6276646">{{cite journal |vauthors=Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D |title=Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases |journal=Medicine (Baltimore) |volume=61 |issue=1 |pages=13–24 |year=1982 |pmid=6276646 |doi= |url=}}</ref><ref name="pmid24503135">{{cite journal |vauthors=Charmandari E, Nicolaides NC, Chrousos GP |title=Adrenal insufficiency |journal=Lancet |volume=383 |issue=9935 |pages=2152–67 |year=2014 |pmid=24503135 |doi=10.1016/S0140-6736(13)61684-0 |url=}}</ref><ref name="pmid27271953">{{cite journal |vauthors=Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ |title=The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study |journal=Clin. Endocrinol. (Oxf) |volume=85 |issue=6 |pages=836–844 |year=2016 |pmid=27271953 |doi=10.1111/cen.13128 |url=}}</ref>
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*No [[dehydration]]
*[[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===
*[[Cyanosis]]  
*[[Pallor]] may be present
*[[Jaundice]]
*[[Bruises]] may be present
* [[Pallor]]
*No [[hyperpigmentation]]
* Bruises
*Alabaster-coloured [[Pallor|pale skin]]
 
*Loss of [[axillary]] or [[pubic]] hair
<gallery widths=150px>
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
* [[Visual field]] defects can be seen such as [[bitemporal hemianopsia]]
*Ophthalmoscopic exam may be abnormal with findings of ___
* 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
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
 
===Neck===
===Neck===
*[[Jugular venous distension]]
*No [[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
* Symmetric [[chest]] expansion
*Lungs are hypo/hyperresonant
* Normal [[tactile fremitus]]
*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
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] , soft and normal
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] normal
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[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===
===Abdomen===
*[[Abdominal distention]]
*No [[abdominal tenderness]]
*[[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===
===Back===
*Point tenderness over __ vertebrae (e.g. L3-L4)
*[[Buffalo hump]] may be present
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Proximal/distal [[muscle weakness]] unilaterally/bilaterally may be present
* Glasgow coma scale is ___ / 15
* [[Bitemporal hemianopsia]] suggestive of [[cranial nerve]] VI compression by a [[pituitary]] [[tumor]]
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*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===
===Extremities===
*[[Clubbing]]  
*Muscle [[atrophy]] may be present
*[[Cyanosis]]  
 
*Pitting/non-pitting [[edema]] of the upper/lower extremities
* If associated with [[hypopituitarism]], patient can present with any one of the following physical signs according to the respective [[hormonal]] deficiency:
*Muscle atrophy
{| class="wikitable"
*Fasciculations in the upper/lower extremity
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Hormonal deficiency
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Finding
|-
| rowspan="2" | '''ACTH'''
|Acute
|
* [[Postural hypotension]]
* [[Tachycardia]]
|-
|[[Chronic]]
|
* [[Anorexia]]
* [[Weight loss]]
* No [[hyperpigmentation]]
|-
|'''TSH'''
| colspan="2" |
* Slow movement and slow speech
 
* Delayed [[relaxation]] of [[Tendon reflex|tendon reflexes]]
 
* [[Bradycardia]]
 
* [[Carotenemia]]
 
* Coarse [[skin]]
 
* Puffy face and loss of [[eyebrows]]
 
* [[Periorbital edema]]
 
* [[Macroglossia|Enlargement of the tongue]]
 
* [[Diastolic blood pressure|Diastolic]] [[hypertension]]
 
* [[Pleural Effusion|Pleural]] and [[Pericardial effusion|pericardial effusions]]
 
* [[Ascites]]
 
* [[Galactorrhea]]
|-
| rowspan="2" |'''Gonadotropins'''
|Male
|
* Soft [[testes]]
* Reduced [[muscle mass]]
* Diminished facial and body hair
* Fine facial wrinkles
* [[Gynecomastia]]
* Regression of [[sexual characteristics]]
|-
|Female
|
* [[Breast]] [[atrophy]]
* Regression of [[sexual characteristics]]
|-
| rowspan="2" |'''Growth hormone'''
|Children
|
* [[Short stature]]
|-
|Adults
|
* Decreased [[sweating]] and impaired [[thermogenesis]]
* Reduced [[muscle mass]] and strength
* Fine [[facial]] wrinkles
* Increased central [[obesity]]
|}


==References==
==References==
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[[Category:Endocrinology]]
[[Category:Endocrinology]]
[[Category:Needs content]]
[[Category:Needs overview]]

Latest revision as of 21:30, 15 November 2017

Secondary adrenal insufficiency Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2] Iqra Qamar M.D.[3]

Overview

Patients with secondary adrenal insufficiency usually appear weak or cushingoid (if the cause is glucocorticoid withdrawal). Physical examination of patients with secondary adrenal insufficiency is usually remarkable for cushingoid features like muscle weakness, buffalo hump. Hypotension may or may not be present. The absence of hyperpigmentation is the hallmark and a distinguishing feature of secondary adrenal insufficiency. Also, the presence of visual field defects like bitemporal hemianopsia indicates a pituitary tumor.

Physical Examination

Appearance of the Patient

Vital Signs

Skin

HEENT

Neck

Lungs

Heart

  • S1 , soft and normal
  • S2 normal

Abdomen

Back

Neuromuscular

Extremities

  • If associated with hypopituitarism, patient can present with any one of the following physical signs according to the respective hormonal deficiency:
Hormonal deficiency Finding
ACTH Acute
Chronic
TSH
  • Slow movement and slow speech
Gonadotropins Male
Female
Growth hormone Children
Adults

References

  1. ↑ Burke CW (1985). "Adrenocortical insufficiency". Clin Endocrinol Metab. 14 (4): 947–76. PMID 3002680.
  2. ↑ Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D (1982). "Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases". Medicine (Baltimore). 61 (1): 13–24. PMID 6276646.
  3. ↑ Charmandari E, Nicolaides NC, Chrousos GP (2014). "Adrenal insufficiency". Lancet. 383 (9935): 2152–67. doi:10.1016/S0140-6736(13)61684-0. PMID 24503135.
  4. ↑ Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ (2016). "The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study". Clin. Endocrinol. (Oxf). 85 (6): 836–844. doi:10.1111/cen.13128. PMID 27271953.


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