Incidentaloma physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
Overview
Most of patients will not show any special signs as the definition of adrenal incidentaloma means incidentaly discovered mass during imaging for ant other reasons. Some cases shows signs of subclinical Cushing's syndrome, pheochromocytoma, or hyperaldosteronism. Common physical examination findings of include patients may appear quite well if the disease is asymptomatic. Patients may appear tired, weak, diaphoretic and anxious. Tachypnea if malignant secondaries are found in the lung with a rapid strong equal pulse and high blood pressure. Jaundice, hyperpigmentation, Telangiectasia, thinning of the skin and easy bruising may be found. A palpable abdominal mass in the lower abdominal quadrant may be found. Hyporeflexia due to low potassium level in aldosternonma, Proximal muscle weakness bilaterally, and bilateral tremors may be found.
Incidentaloma physical examination
Physical Examination of subclinical Cushing's syndrome
Physical examination of patients with subclinical Cushing's syndrome is as follows:[1]
Appearance of the patient
- Patients with Cushing's syndrome usually appears overweight.
Vital signs
- Hypertension, due to cortisol's enhancement of epinephrine's vasoconstrictive effect.
Head
- Moon-face is a medical sign where the face swells up into a rounded shape. It is often associated with Cushing's syndrome, which has led to it being known as Cushingoid facies ("Cushings-like face"), or steroid treatment, which has led to the name steroid facies.
Skin
- Hyperpigmentation - this is due to Melanocyte-Stimulating Hormone production as a byproduct of ACTH synthesis from Proopiomelanocortin (POMC)
- Telangiectasia (dilation of capillaries)
- Thinning of the skin (which causes easy bruising)
- Purple or red striae (the weight gain in Cushing's stretches the skin, which is thin and weakened, causing it to hemorrhage) on the trunk, buttocks, arms, legs or breasts, proximal muscle weakness (hips, shoulders)
- Hirsutism (facial male-pattern hair growth)
Eye
- Bitemporal hemianopsia - pituitary lesion may compress the optic chiasm
Neck
- Growth of fat pads along the collar bone and on the back of the neck (known as a lipodystrophy)
Physical Examination of pheochromocytoma
Appearance of the Patient
- Patients may appear tired, weak, diaphoretic and anxious.[2]
- Patients may appear quite well if the disease is asymptomatic.
- Patients may appear flushed due to associated increase in erythropoietin secretion.[3]
- Patients may appear obese due to associated type2 diabetes mellitus and Cushing's syndrome.[4]
Vital Signs
- 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.
- 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.
Head
- Facial flushing.
- Scleral icterus in case of metastasis to the liver.
- MEN2 patients associated with mucosal neuromas show multiple lips and tongue neuromas.
Neck
- Congested neck veins in patients with cardiomyopathy.[5]
- Painless lymphadenopathy if malignant secondaries found in the neck (rapid increase in the size of the node. Prevalence of malignancy in lymph node biopsies performed is 60%.[6]
- Thyromegaly/thyroid nodules if MEN patients due to medullary thyroid cancer.[7]
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: Precordial heave especially at apex due to left ventricular hypertrophy in long standing patients.
- Auscultation: normal S1 and accentuated S2 due to high systemic resistance.
Abdomen
- Abdominal distention in patients with primary hyperparathyroidism associated constipation or Hirschsprung disease.
- Abdominal tenderness in the lower abdominal quadrants in MEN2 patients with Hirschsprung disease.[8]
- A palpable abdominal mass in the lower abdominal quadrant.
- Guarding may be present.
- Hepatomegaly if malignant secondaries found in liver.
- Diarrhea caused by gastrointestinal secretion of fluid and electrolytes, and flushing in medullary thyroid cancer patients.[9]
Back
- Point tenderness in MEN1 patients with hyperparathyroidism.
Appearance of the Patient
- Patients may appear quite well if the disease is asymptomatic.
- Patients may appear tired, weak, diaphoretic and anxious.[2]
- Patients may appear flushed due to associated increase in erythropoietin secretion.[3]
- Patients may appear obese due to associated type2 diabetes mellitus and Cushing's syndrome.[4]
- Patients with Cushing's syndrome usually appears overweight.
Vital Signs
- Tachycardia with a regular pulse but 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.
- Rapid strong equal pulse
- High blood pressure with normal pulse pressure
- Hypotension occurs due to fluid contraction
- Hypertension, due to cortisol's enhancement of epinephrine's vasoconstrictive effect
Skin
- Jaundice secondary to deranged liver function in case of metastasis to the liver.
- Hyperpigmentation - this is due to Melanocyte-Stimulating Hormone production as a byproduct of ACTH synthesis from Proopiomelanocortin (POMC)
- Telangiectasia (dilation of capillaries)
- Thinning of the skin (which causes easy bruising)
- Purple or red striae (the weight gain in Cushing's stretches the skin, which is thin and weakened, causing it to hemorrhage) on the trunk, buttocks, arms, legs or breasts, proximal muscle weakness (hips, shoulders)
- Hirsutism (facial male-pattern hair growth)
HEENT
- Facial flushing
- Scleral icterus in case of metastasis to the liver
- MEN2 patients associated with mucosal neuromas show multiple lips and tongue neuromas.
- Moon-face is a medical sign where the face swells up into a rounded shape. It is often associated with Cushing's syndrome, which has led to it being known as Cushingoid facies ("Cushings-like face"), or steroid treatment, which has led to the name steroid facies.
Neck
- Congested neck veins in patients with cardiomyopathy[5]
- Painless lymphadenopathy if malignant secondaries found in the neck (rapid increase in the size of the node. Prevalence of malignancy in lymph node biopsies performed is 60%
- Thyromegaly/thyroid nodules if MEN patients due to medullary thyroid cancer.[9]
- Growth of fat pads along the collar bone and on the back of the neck.
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: Precordial heave especially at apex due to left ventricular hypertrophy in long standing patients.
- Auscultation: normal S1 and accentuated S2 due to high systemic resistance.
Abdomen
- Abdominal distention in patients with primary hyperparathyroidism associated constipation or Hirschsprung disease.
- Abdominal tenderness in the lower abdominal quadrants in MEN2 patients with Hirschsprung disease.[8]
- A palpable abdominal mass in the lower abdominal quadrant.
- Guarding may be present.
- Hepatomegaly if malignant secondaries found in liver.
- Diarrhea caused by gastrointestinal secretion of fluid and electrolytes, and flushing in medullary thyroid cancer patients.
Back
- Point tenderness in MEN1 patients with hyperparathyroidism
Neuromuscular
- Hyporeflexia due to low potassium level in aldosternonma
- Proximal muscle weakness bilaterally
- Bilateral tremors
Extremities
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
References
- ↑ Nieman LK (2015). "Cushing's syndrome: update on signs, symptoms and biochemical screening". Eur. J. Endocrinol. 173 (4): M33–8. doi:10.1530/EJE-15-0464. PMC 4553096. PMID 26156970.
- ↑ 2.0 2.1 Bravo EL, Gifford RW (1993). "Pheochromocytoma". Endocrinol Metab Clin North Am. 22 (2): 329–41. PMID 8325290.
- ↑ 3.0 3.1 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.
- ↑ 4.0 4.1 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.
- ↑ 5.0 5.1 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.
- ↑ HEINRICH WA, JUDD ES (1948). "A critical analysis of biopsy of lymph nodes". Proc Staff Meet Mayo Clin. 23 (21): 465–9. PMID 18888946.
- ↑ 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.
- ↑ 8.0 8.1 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.
- ↑ 9.0 9.1 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.