Pituitary apoplexy physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Pituitary apoplexy}} | {{Pituitary apoplexy}} | ||
{{CMG}} | {{CMG}} {{AE}}{{Akshun}} | ||
== Overview == | |||
Patients with pituitary apoplexy appear ill and usually look [[tired]]. [[Physical examination]] of patients with pituitary apoplexy is usually remarkable for [[orthostatic hypotension]], [[visual acuity]] and [[Visual field defect|visual field defects]], [[cranial nerve palsies]], [[Horner syndrome]], [[meningeal irritation]], altered level of [[consciousness]], severe [[mental status]] change, and other [[signs]] of [[hypopituitarism]]. | |||
==Physical Examination== | ==Physical Examination== | ||
=== | ===Appearance of the patient=== | ||
* [[ | *[[Patients]] of [[hypopituitarism]] appear ill and usually look [[tired]].<ref name="FleseriuHashim2016">{{cite journal|last1=Fleseriu|first1=Maria|last2=Hashim|first2=Ibrahim A.|last3=Karavitaki|first3=Niki|last4=Melmed|first4=Shlomo|last5=Murad|first5=M. Hassan|last6=Salvatori|first6=Roberto|last7=Samuels|first7=Mary H.|title=Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=101|issue=11|year=2016|pages=3888–3921|issn=0021-972X|doi=10.1210/jc.2016-2118}}</ref><ref name="pmid16597813">{{cite journal| author=Prabhakar VK, Shalet SM| title=Aetiology, diagnosis, and management of hypopituitarism in adult life. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 966 | pages= 259-66 | pmid=16597813 | doi=10.1136/pgmj.2005.039768 | pmc=2585697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16597813 }} </ref><ref name="AscoliCavagnini2006">{{cite journal|last1=Ascoli|first1=Paola|last2=Cavagnini|first2=Francesco|title=Hypopituitarism|journal=Pituitary|volume=9|issue=4|year=2006|pages=335–342|issn=1386-341X|doi=10.1007/s11102-006-0416-5}}</ref> | ||
===Skin=== | ===Vital Signs=== | ||
* [[Dry skin]] | * [[Orthostatic hypotension|Orthostatic hypotension]] | ||
=== Skin === | |||
* [[Dry skin]] | |||
* [[Pallor]] | |||
* Loss of [[hair]] | |||
===Eye=== | ===Eye=== | ||
* Visual acuity defects (52%) and visual field defects (64%) result from upward expansion of the tumor | * [[Visual acuity]] defects (52%) and [[Visual field defect|visual field defects]] (64%) result from the upward expansion of the [[tumor]]. Superior expansion of the [[tumor]] causes dysfunction of the [[optic nerve]] and [[optic chiasm]]. The most common [[visual field defect]] is a bitemporal superior quadratic defect. Less commonly, [[optic tract]] involvement from a prefixed [[Chiasma|chiasm]] results in a contralateral [[Homonymous hemianopsia|homonymous hemianopia]]. [[Optic nerve]] compression from a postfixed [[Chiasma|chiasm]] is rare and may mimic [[optic neuritis]] with pain on [[eye movement]], monocular [[visual acuity]] loss, and a central [[scotoma]] on [[visual field testing]].<ref name="pmid18588383">{{cite journal| author=Bahmani Kashkouli M, Khalatbari MR, Yahyavi ST, Borghei-Razavi H, Soltan-Sanjari M| title=Pituitary apoplexy presenting as acute painful isolated unilateral third cranial nerve palsy. | journal=Arch Iran Med | year= 2008 | volume= 11 | issue= 4 | pages= 466-8 | pmid=18588383 | doi=08114/AIM.0022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18588383 }} </ref> | ||
* [[Cranial nerve palsies]] (nerves III, IV, V, and VI). Lateral expansion of the [[pituitary adenoma]] into the [[cavernous sinus]] is usually presented. If [[consciousness]] is maintained, [[diplopia]] may be present. Of the [[cranial nerves]]: | |||
** Cranial nerve III ([[oculomotor nerve]]) is involved most commonly, resulting in a unilateral [[dilated pupil]], [[ptosis]], and [[eye]] that is deviated inferiorly and laterally. | |||
** Cranial nerve IV ([[trochlear nerve]]) palsy typically manifests as vertical [[diplopia]] that worsens when the patient gazes in a direction opposite or tilts the [[head]] toward the direction of the affected [[eye]]. | |||
** Cranial nerve V ([[trigeminal nerve]]) involvement may produce facial pain or [[sensory loss]]. | |||
** Cranial nerve VI ([[Abducens nerve|abducent nerve]]) is least commonly involved, perhaps because of its sheltered position in the [[cavernous sinus]]. Its involvement produces horizontal [[diplopia]], which results from an inability to abduct the involved [[eye]]. | |||
* [[Horner's syndrome|Horner syndrome]] may develop from damage to the [[sympathetic fibers]]. Hemispheric deficits may also develop. | |||
=== | ===Neurologic=== | ||
* [[ | * Signs of [[meningeal irritation]]: The [[hemorrhagic]] expansion may disrupt the dural covering of the [[Pituitary gland|pituitary]], thus allowing [[blood]] to enter the [[subarachnoid space]] to produce [[meningeal irritation]]. Therefore, retro orbital [[headache]] is the most common presenting [[symptom]] in a [[conscious]] patient.<ref name="pmid21082047">{{cite journal| author=Woo HJ, Hwang JH, Hwang SK, Park YM| title=Clinical outcome of cranial neuropathy in patients with pituitary apoplexy. | journal=J Korean Neurosurg Soc | year= 2010 | volume= 48 | issue= 3 | pages= 213-8 | pmid=21082047 | doi=10.3340/jkns.2010.48.3.213 | pmc=2966721 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21082047 }} </ref> | ||
* Altered level of [[consciousness]] is due to compression of the [[internal carotid artery]] which may present a rapid downhill course. | |||
* Severe [[mental status]] change is an indication for rapid neurosurgical decompression. | |||
* Delayed [[reflexes]] | |||
=== Lungs === | |||
* [[Dyspnea]] | |||
* [[Shortness of breath]] | |||
=== Heart === | |||
* [[Bradycardia]] | |||
* [[Atherosclerosis]] | |||
=== Abdomen === | |||
* [[Rebound tenderness]] | |||
=== Neuromuscular === | |||
* [[Muscle weakness]] | |||
* [[Osteoporosis]] | |||
=== | ===Genitourinary === | ||
* | * [[Hypogonadism]] ([[Micropenis]]) | ||
* [[Erectile dysfunction]] | |||
===Extremities=== | |||
* [[Atrophy]] of [[Limb (anatomy)|limbs]] | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Endocrinology]] | [[Category:Endocrinology]] | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Medicine]] | |||
[[Category:Up-To-Date]] | |||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 16:23, 18 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]
Overview
Patients with pituitary apoplexy appear ill and usually look tired. Physical examination of patients with pituitary apoplexy is usually remarkable for orthostatic hypotension, visual acuity and visual field defects, cranial nerve palsies, Horner syndrome, meningeal irritation, altered level of consciousness, severe mental status change, and other signs of hypopituitarism.
Physical Examination
Appearance of the patient
Vital Signs
Skin
Eye
- Visual acuity defects (52%) and visual field defects (64%) result from the upward expansion of the tumor. Superior expansion of the tumor causes dysfunction of the optic nerve and optic chiasm. The most common visual field defect is a bitemporal superior quadratic defect. Less commonly, optic tract involvement from a prefixed chiasm results in a contralateral homonymous hemianopia. Optic nerve compression from a postfixed chiasm is rare and may mimic optic neuritis with pain on eye movement, monocular visual acuity loss, and a central scotoma on visual field testing.[4]
- Cranial nerve palsies (nerves III, IV, V, and VI). Lateral expansion of the pituitary adenoma into the cavernous sinus is usually presented. If consciousness is maintained, diplopia may be present. Of the cranial nerves:
- Cranial nerve III (oculomotor nerve) is involved most commonly, resulting in a unilateral dilated pupil, ptosis, and eye that is deviated inferiorly and laterally.
- Cranial nerve IV (trochlear nerve) palsy typically manifests as vertical diplopia that worsens when the patient gazes in a direction opposite or tilts the head toward the direction of the affected eye.
- Cranial nerve V (trigeminal nerve) involvement may produce facial pain or sensory loss.
- Cranial nerve VI (abducent nerve) is least commonly involved, perhaps because of its sheltered position in the cavernous sinus. Its involvement produces horizontal diplopia, which results from an inability to abduct the involved eye.
- Horner syndrome may develop from damage to the sympathetic fibers. Hemispheric deficits may also develop.
Neurologic
- Signs of meningeal irritation: The hemorrhagic expansion may disrupt the dural covering of the pituitary, thus allowing blood to enter the subarachnoid space to produce meningeal irritation. Therefore, retro orbital headache is the most common presenting symptom in a conscious patient.[5]
- Altered level of consciousness is due to compression of the internal carotid artery which may present a rapid downhill course.
- Severe mental status change is an indication for rapid neurosurgical decompression.
- Delayed reflexes
Lungs
Heart
Abdomen
Neuromuscular
Genitourinary
Extremities
References
- ↑ Fleseriu, Maria; Hashim, Ibrahim A.; Karavitaki, Niki; Melmed, Shlomo; Murad, M. Hassan; Salvatori, Roberto; Samuels, Mary H. (2016). "Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 101 (11): 3888–3921. doi:10.1210/jc.2016-2118. ISSN 0021-972X.
- ↑ Prabhakar VK, Shalet SM (2006). "Aetiology, diagnosis, and management of hypopituitarism in adult life". Postgrad Med J. 82 (966): 259–66. doi:10.1136/pgmj.2005.039768. PMC 2585697. PMID 16597813.
- ↑ Ascoli, Paola; Cavagnini, Francesco (2006). "Hypopituitarism". Pituitary. 9 (4): 335–342. doi:10.1007/s11102-006-0416-5. ISSN 1386-341X.
- ↑ Bahmani Kashkouli M, Khalatbari MR, Yahyavi ST, Borghei-Razavi H, Soltan-Sanjari M (2008). "Pituitary apoplexy presenting as acute painful isolated unilateral third cranial nerve palsy". Arch Iran Med. 11 (4): 466–8. doi:08114/AIM.0022 Check
|doi=value (help). PMID 18588383. - ↑ Woo HJ, Hwang JH, Hwang SK, Park YM (2010). "Clinical outcome of cranial neuropathy in patients with pituitary apoplexy". J Korean Neurosurg Soc. 48 (3): 213–8. doi:10.3340/jkns.2010.48.3.213. PMC 2966721. PMID 21082047.