Adrenal insufficiency physical examination: Difference between revisions

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Created page with "__NOTOC__ {{Adrenal insufficiency}} {{CMG}}; {{AE}} ==Overview== Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [dis..."
 
 
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{{Adrenal insufficiency}}
{{Adrenal insufficiency}}


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{Ayeesha}}


==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 [[adrenal insufficiency]] usually appear [[dehydrated]] and weak. Physical examination of patients with [[primary adrenal insufficiency]] is usually remarkable for hyperpigmentation of skin.
 
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 normal.
Physical examination of patients with [[primary adrenal insufficiency]] is usually remarkable for hyperpigmentation of skin. <ref name="LeeCho2017">{{cite journal|last1=Lee|first1=Ye Yeon|last2=Cho|first2=Nan Hee|last3=Lee|first3=Jong Won|last4=Kim|first4=Nam Kyung|last5=Kim|first5=Hye Soon|last6=Kim|first6=Mi-Kyung|title=Clinical Characteristics of Patients with Adrenal Insufficiency in a General Hospital|journal=Endocrinology and Metabolism|volume=32|issue=1|year=2017|pages=83|issn=2093-596X|doi=10.3803/EnM.2017.32.1.83}}</ref>
 
OR
 
Physical examination of patients with [disease name] is usually remarkable for [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].


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with [[adrenal insufficiency]] usually appear [[dehydrated]] or weak.


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
*Fever maybe present in [[adrenal insufficiency]]. <ref name="pmid28722862">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=28722862 | doi= | pmc= | url= }} </ref>
*[[Hypothermia]] / hyperthermia may be present
*Low blood pressure with normal pulse pressure is seen, especially in [[primary adrenal insufficiency due to [[mineralocorticoid]] deficiency.
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Adrenal crisis]] presents with [[hypotension]], [[tachycardia]], [[hypovolemia]]. <ref name="PazderskaPearce2017">{{cite journal|last1=Pazderska|first1=Agnieszka|last2=Pearce|first2=Simon HS|title=Adrenal insufficiency – recognition and management|journal=Clinical Medicine|volume=17|issue=3|year=2017|pages=258–262|issn=1470-2118|doi=10.7861/clinmedicine.17-3-258}}</ref>
*[[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===
* Skin examination of patients with [disease name] is usually normal.
* Skin examination of patients with [[primary adrenal insufficiency]] includes: <ref name="pmid29184811">{{cite journal| author=Lause M, Kamboj A, Fernandez Faith E| title=Dermatologic manifestations of endocrine disorders. | journal=Transl Pediatr | year= 2017 | volume= 6 | issue= 4 | pages= 300-312 | pmid=29184811 | doi=10.21037/tp.2017.09.08 | pmc=5682371 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29184811  }} </ref>
OR
*[[Hyperpigmentation]], commonly affecting the palmar creases, perineum, axilla, and areola. It is most prominent in areas exposed to trauma, pressure and sun.
*[[Cyanosis]]  
*Mucosal hyperpigmentation commonly effects [[buccal]], [[gingival]], [[tongue]], vermillion border of lips. <ref name="SarkarSarkar2012">{{cite journal|last1=Sarkar|first1=SoumyaBrata|last2=Sarkar|first2=Subrata|last3=Ghosh|first3=Supratim|last4=Bandyopadhyay|first4=Subhankar|title=Addison′s disease|journal=Contemporary Clinical Dentistry|volume=3|issue=4|year=2012|pages=484|issn=0976-237X|doi=10.4103/0976-237X.107450}}</ref>
*[[Jaundice]]
*Loss of axillary and pubic hair in women with [[primary adrenal insufficiency]]
* [[Pallor]]
*Horizontal bands of [[hyperpigmentation]] on the nails.
* Bruises
 
<gallery widths="150px">


UploadedImage-01.jpg | Description {{dermref}}
Following image shows mucosal hyperpigmentation in Addison's disease:
UploadedImage-02.jpg | Description {{dermref}}


</gallery>
[[Image:Addisons hyperpigmentation.jpg|thumb|center|500px|Mucosal hyperpigmentation - By FlatOut - Dermatology Online Journal http://dermatology.cdlib.org/, CC0, https://commons.wikimedia.org/w/index.php?curid=25847348]]


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* HEENT examination of patients with [[adrenal insufficiency]] is usually normal.
OR
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]  
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*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===
* Neck examination of patients with [disease name] is usually normal.
* Neck examination of patients with [[adrenal insufficiency]] is usually normal.
OR
*[[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===
* Pulmonary examination of patients with [disease name] is usually normal.
* Pulmonary examination of patients with [[adrenal insufficiency]] is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
* Cardiovascular examination of patients with [[adrenal insufficiency]] is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[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 stethoscope


===Abdomen===
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
*[[Abdominal tenderness]] and [[guarding]] can be present in [[adrenal crisis]] <ref>https://www.amjmed.com/article/S0002-9343(15)00827-X/pdf</ref>
OR
*[[Abdominal distension]]  
*[[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===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with [[adrenal insufficiency]] is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
* Genitourinary examination of patients with [[adrenal insufficiency]] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
* Altered mental status maybe seen in patients with [[adrenal crisis]] <ref>https://www.amjmed.com/article/S0002-9343(15)00827-X/pdf</ref>
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Glasgow coma scale is ___ / 15
* 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===
* Extremities examination of patients with [disease name] is usually normal.
* Extremities examination of patients with [[adrenal insufficiency]] is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==

Latest revision as of 18:13, 7 December 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayeesha Kattubadi, M.B.B.S[2]

Overview

Patients with adrenal insufficiency usually appear dehydrated and weak. Physical examination of patients with primary adrenal insufficiency is usually remarkable for hyperpigmentation of skin.

Physical Examination

Physical examination of patients with primary adrenal insufficiency is usually remarkable for hyperpigmentation of skin. [1]

Appearance of the Patient

Vital Signs

Skin

Following image shows mucosal hyperpigmentation in Addison's disease:

Mucosal hyperpigmentation - By FlatOut - Dermatology Online Journal http://dermatology.cdlib.org/, CC0, https://commons.wikimedia.org/w/index.php?curid=25847348

HEENT

Neck

Lungs

Heart

Abdomen

Back

Genitourinary

Neuromuscular

Extremities

References

  1. ↑ Lee, Ye Yeon; Cho, Nan Hee; Lee, Jong Won; Kim, Nam Kyung; Kim, Hye Soon; Kim, Mi-Kyung (2017). "Clinical Characteristics of Patients with Adrenal Insufficiency in a General Hospital". Endocrinology and Metabolism. 32 (1): 83. doi:10.3803/EnM.2017.32.1.83. ISSN 2093-596X.
  2. ↑ "StatPearls". 2020. PMID 28722862.
  3. ↑ Pazderska, Agnieszka; Pearce, Simon HS (2017). "Adrenal insufficiency – recognition and management". Clinical Medicine. 17 (3): 258–262. doi:10.7861/clinmedicine.17-3-258. ISSN 1470-2118.
  4. ↑ Lause M, Kamboj A, Fernandez Faith E (2017). "Dermatologic manifestations of endocrine disorders". Transl Pediatr. 6 (4): 300–312. doi:10.21037/tp.2017.09.08. PMC 5682371. PMID 29184811.
  5. ↑ Sarkar, SoumyaBrata; Sarkar, Subrata; Ghosh, Supratim; Bandyopadhyay, Subhankar (2012). "Addison′s disease". Contemporary Clinical Dentistry. 3 (4): 484. doi:10.4103/0976-237X.107450. ISSN 0976-237X.
  6. ↑ https://www.amjmed.com/article/S0002-9343(15)00827-X/pdf
  7. ↑ https://www.amjmed.com/article/S0002-9343(15)00827-X/pdf

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