Pheochromocytoma physical examination: Difference between revisions

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{{Pheochromocytoma}}
{{Pheochromocytoma}}
{{CMG}}; {{AE}} {{AAM}}
{{CMG}} {{AE}} {{AAM}} {{MAD}}


==Overview==
==Overview==
Common physical exam findings of pheochromocytoma include [[tachycardia]], [[hypertension]], and [[orthostatic hypotension]].
Patients with [[pheochromocytoma]] usually appear [[diaphoretic]] and [[anxious]]. Physical examination of patients with [[pheochromocytoma]] is usually remarkable for  [[tachycardia]], [[hypertension]], and [[orthostatic hypotension]].


==Physical Examination==
==Physical Examination==
Common physical exam findings include:
Physical examination of patients with [[pheochromocytoma]] is usually remarkable for  [[tachycardia]], [[hypertension]], and [[orthostatic hypotension]].
*[[Tachycardia]]
 
*[[Hypertension]], including paroxysmal (sporadic, episodic) high blood pressure, which sometimes can be more difficult to detect.
=== Appearance of the Patient ===
*[[Orthostatic hypotension]]
* Patients with [[pheochromocytoma]] usually appear tired, weak, [[diaphoretic]] and [[anxious]].<ref name="pmid8325290">{{cite journal| author=Bravo EL, Gifford RW| title=Pheochromocytoma. | journal=Endocrinol Metab Clin North Am | year= 1993 | volume= 22 | issue= 2 | pages= 329-41 | pmid=8325290 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8325290  }}</ref>
* Patients may appear quite well if the [[disease]] is [[asymptomatic]].
* Patients may appear [[Flushing|flushed]] due to associated increase in [[erythropoietin]] secretion.<ref name="pmid7567437">{{cite journal| author=Drénou B, Le Tulzo Y, Caulet-Maugendre S, Le Guerrier A, Leclercq C, Guilhem I et al.| title=Pheochromocytoma and secondary erythrocytosis: role of tumour erythropoietin secretion. | journal=Nouv Rev Fr Hematol | year= 1995 | volume= 37 | issue= 3 | pages= 197-9 | pmid=7567437 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7567437  }}</ref>
* Patients may appear [[obese]] due to associated type 2 [[diabetes mellitus]] and [[Cushing's syndrome]].<ref name="pmid12923403">{{cite journal| author=La Batide-Alanore A, Chatellier G, Plouin PF| title=Diabetes as a marker of pheochromocytoma in hypertensive patients. | journal=J Hypertens | year= 2003 | volume= 21 | issue= 9 | pages= 1703-7 | pmid=12923403 | doi=10.1097/01.hjh.0000084729.53355.ce | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12923403  }}</ref>
 
=== Vital Signs ===
* Hyperthermia may be present <ref name="pmid24176474">{{cite journal| author=Tenner AG, Halvorson KM| title=Endocrine causes of dangerous fever. | journal=Emerg Med Clin North Am | year= 2013 | volume= 31 | issue= 4 | pages= 969-86 | pmid=24176474 | doi=10.1016/j.emc.2013.07.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24176474  }} </ref>
* [[Tachycardia]] with a regular pulse. Irregular pulse may occurr in [[supraventricular tachycardia]].
* [[Tachypnea]] if [[malignant]] secondaries are found in the [[lung]]. [[Dyspnea]] occurs in patients with complicated [[heart failure]] and [[Cardiomyopathy|cardiomyopathy.]]
* Rapid strong equal [[pulse]].
* High [[blood pressure]] with normal [[pulse pressure]].
* [[Hypotension]] occurs due to fluid contraction.
 
=== Skin ===
* [[Jaundice]] secondary to deranged [[liver]] function in case of [[metastasis]] to the [[liver]].
 
=== HEENT===
* [[Facial flushing]].
* [[Icterus|Scleral icterus]] in case of [[metastasis]] to the [[liver]].
* [[MEN2]] patients associated with [[mucosal]] [[Neuroma|neuromas]] show multiple lips and tongue [[Neuroma|neuromas]].
 
=== Neck ===
* Congested [[neck veins]] in patients with [[cardiomyopathy|cardiomyopathy.]]<ref name="pmid19158054">{{cite journal| author=Kassim TA, Clarke DD, Mai VQ, Clyde PW, Mohamed Shakir KM| title=Catecholamine-induced cardiomyopathy. | journal=Endocr Pract | year= 2008 | volume= 14 | issue= 9 | pages= 1137-49 | pmid=19158054 | doi=10.4158/EP.14.9.1137 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19158054  }}</ref>
 
* Painless [[lymphadenopathy]] if [[malignant]] secondaries found in the neck (rapid increase in the size of the [[Lymph node|node]]. [[Prevalence]] of [[malignancy]] in [[Lymph node biopsy|lymph node biopsies]] performed is 60%.<ref name="pmid18888946">{{cite journal| author=HEINRICH WA, JUDD ES| title=A critical analysis of biopsy of lymph nodes. | journal=Proc Staff Meet Mayo Clin | year= 1948 | volume= 23 | issue= 21 | pages= 465-9 | pmid=18888946 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18888946  }}</ref>
* [[Thyromegaly]]/[[thyroid]] [[nodules]] if [[Multiple endocrine neoplasia|MEN]] patients due to [[medullary thyroid cancer]].<ref name="pmid258100472">{{cite journal| author=Wells SA, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF et al.| title=Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. | journal=Thyroid | year= 2015 | volume= 25 | issue= 6 | pages= 567-610 | pmid=25810047 | doi=10.1089/thy.2014.0335 | pmc=4490627 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25810047  }}</ref>
 
=== Lungs ===
* Asymmetric [[chest]] expansion / decreased [[chest]] expansion if [[malignant]] secondaries are found in the [[lung]].
 
=== Heart ===
* Chest [[tenderness]] upon [[palpation]] in [[MEN1]] patients due to [[hyperparathyroidism]].
* [[Palpation]]: [[Precordium|Precordial]] [[heave]] especially at apex due to [[left ventricular hypertrophy]] in long standing patients.
* Auscultation: normal [[Heart sounds|S1]] and accentuated [[Heart sounds|S2]] due to high systemic resistance.
 
=== Abdomen ===
* [[Abdominal distention]] in patients with [[primary hyperparathyroidism]] associated [[constipation]] or [[Hirschsprung's disease|Hirschsprung disease]].
* [[Abdominal tenderness]] in the lower [[abdominal]] quadrants in [[Multiple endocrine neoplasia type 2|MEN2]] patients with [[Hirschsprung disease|Hirschsprung disease.]]<ref name="pmid7491537">{{cite journal| author=O'Riordain DS, O'Brien T, Crotty TB, Gharib H, Grant CS, van Heerden JA| title=Multiple endocrine neoplasia type 2B: more than an endocrine disorder. | journal=Surgery | year= 1995 | volume= 118 | issue= 6 | pages= 936-42 | pmid=7491537 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7491537  }}</ref>
* A palpable [[abdominal mass]] in the lower [[abdominal]] quadrant.
* [[Abdominal guarding|Guarding]] may be present.
* [[Hepatomegaly]] if [[malignant]] secondaries found in [[liver]].
* [[Diarrhea]] caused by [[gastrointestinal]] secretion of fluid and [[Electrolyte|electrolytes]], and [[flushing]] in [[medullary thyroid cancer]] patients.<ref name="pmid25810047">{{cite journal| author=Wells SA, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF et al.| title=Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. | journal=Thyroid | year= 2015 | volume= 25 | issue= 6 | pages= 567-610 | pmid=25810047 | doi=10.1089/thy.2014.0335 | pmc=4490627 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25810047  }}</ref>
 
=== Back ===
* Point [[tenderness]] in [[MEN1]] patients with [[hyperparathyroidism]].
 
===Genitourinary===
* Genitourinary examination of patients with [[pheochromocytoma]] is usually normal.
 
===Neuromuscular===
*Patient is usually oriented to person, place, and time; disorientation may be seen if [[pheochromocytoma]] precipitates [[hypertensive encephalopathy]].
* Altered mental status may be present if [[pheochromocytoma]] precipitates [[hypertensive encephalopathy]]. <ref name="pmid32595044">{{cite journal| author=| title=Correction to Lancet Infectious Diseases 2020; published online April 29. https://doi.org/10.1016/ S1473-3099(20)30064-5. | journal=Lancet Infect Dis | year= 2020 | volume= 20 | issue= 7 | pages= e148 | pmid=32595044 | doi=10.1016/S1473-3099(20)30370-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32595044  }} </ref>
*[[Hyperreflexia]] <ref name="pmid475568">{{cite journal| author=Manger WM, Davis SW, Chu DS| title=Autonomic hyperreflexia and its differentiation from pheochromocytoma. | journal=Arch Phys Med Rehabil | year= 1979 | volume= 60 | issue= 4 | pages= 159-61 | pmid=475568 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=475568  }} </ref>
* In case of [[Stroke|acute stroke]] due to paroxysmal [[hypertension]], the following may be seen:
** Corresponding [[Cranial nerves|cranial nerve]] deficit
** Unilateral/bilateral upper/lower [[Weakness|extremity weakness]]
**Unilateral/[[bilateral]] [[sensory loss]] in the upper/lower extremity
*[[Bilateral]] [[tremor]] at rest
 
===Extremities===
*[[Bilateral]] generalized [[Tremor|tremors]]


==References==
==References==
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Latest revision as of 21:16, 28 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ahmad Al Maradni, M.D. [2] Mohammed Abdelwahed M.D[3]

Overview

Patients with pheochromocytoma usually appear diaphoretic and anxious. Physical examination of patients with pheochromocytoma is usually remarkable for tachycardia, hypertension, and orthostatic hypotension.

Physical Examination

Physical examination of patients with pheochromocytoma is usually remarkable for tachycardia, hypertension, and orthostatic hypotension.

Appearance of the Patient

Vital Signs

Skin

HEENT

Neck

Lungs

Heart

Abdomen

Back

Genitourinary

Neuromuscular

Extremities

References

  1. ↑ Bravo EL, Gifford RW (1993). "Pheochromocytoma". Endocrinol Metab Clin North Am. 22 (2): 329–41. PMID 8325290.
  2. ↑ Drénou B, Le Tulzo Y, Caulet-Maugendre S, Le Guerrier A, Leclercq C, Guilhem I; et al. (1995). "Pheochromocytoma and secondary erythrocytosis: role of tumour erythropoietin secretion". Nouv Rev Fr Hematol. 37 (3): 197–9. PMID 7567437.
  3. ↑ La Batide-Alanore A, Chatellier G, Plouin PF (2003). "Diabetes as a marker of pheochromocytoma in hypertensive patients". J Hypertens. 21 (9): 1703–7. doi:10.1097/01.hjh.0000084729.53355.ce. PMID 12923403.
  4. ↑ Tenner AG, Halvorson KM (2013). "Endocrine causes of dangerous fever". Emerg Med Clin North Am. 31 (4): 969–86. doi:10.1016/j.emc.2013.07.010. PMID 24176474.
  5. ↑ Kassim TA, Clarke DD, Mai VQ, Clyde PW, Mohamed Shakir KM (2008). "Catecholamine-induced cardiomyopathy". Endocr Pract. 14 (9): 1137–49. doi:10.4158/EP.14.9.1137. PMID 19158054.
  6. ↑ HEINRICH WA, JUDD ES (1948). "A critical analysis of biopsy of lymph nodes". Proc Staff Meet Mayo Clin. 23 (21): 465–9. PMID 18888946.
  7. ↑ Wells SA, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF; et al. (2015). "Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma". Thyroid. 25 (6): 567–610. doi:10.1089/thy.2014.0335. PMC 4490627. PMID 25810047.
  8. ↑ O'Riordain DS, O'Brien T, Crotty TB, Gharib H, Grant CS, van Heerden JA (1995). "Multiple endocrine neoplasia type 2B: more than an endocrine disorder". Surgery. 118 (6): 936–42. PMID 7491537.
  9. ↑ Wells SA, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF; et al. (2015). "Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma". Thyroid. 25 (6): 567–610. doi:10.1089/thy.2014.0335. PMC 4490627. PMID 25810047.
  10. ↑ "Correction to Lancet Infectious Diseases 2020; published online April 29. https://doi.org/10.1016/ S1473-3099(20)30064-5". Lancet Infect Dis. 20 (7): e148. 2020. doi:10.1016/S1473-3099(20)30370-4. PMID 32595044 Check |pmid= value (help). External link in |title= (help)
  11. ↑ Manger WM, Davis SW, Chu DS (1979). "Autonomic hyperreflexia and its differentiation from pheochromocytoma". Arch Phys Med Rehabil. 60 (4): 159–61. PMID 475568.
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