Secondary adrenal insufficiency physical examination: Difference between revisions

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{{Secondary adrenal insufficiency}}
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==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===
*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===
*Low-grade [[fever]] may be present
*[[Tachycardia]] 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>
*No [[dehydration]]
 
===Skin===
*[[Pallor]] may be present
*[[Bruises]] may be present
*No [[hyperpigmentation]]
*Alabaster-coloured [[Pallor|pale skin]]
*Loss of [[axillary]] or [[pubic]] hair
 
===HEENT===
* Extra-ocular movements may be abnormal
* [[Visual field]] defects can be seen such as [[bitemporal hemianopsia]]
===Neck===
*No [[Jugular venous distension]]
 
===Lungs===
* Symmetric [[chest]] expansion
* Normal [[tactile fremitus]]
 
===Heart===
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] , soft and normal
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] normal
 
===Abdomen===
*No [[abdominal tenderness]]
 
===Back===
*[[Buffalo hump]] may be present
 
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
* Proximal/distal [[muscle weakness]] unilaterally/bilaterally may be present
* [[Bitemporal hemianopsia]] suggestive of [[cranial nerve]] VI compression by a [[pituitary]] [[tumor]]
 
===Extremities===
*Muscle [[atrophy]] may be present
 
* If associated with [[hypopituitarism]], patient can present with any one of the following physical signs according to the respective [[hormonal]] deficiency:
{| class="wikitable"
! 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]]


{{CMG}}
* Coarse [[skin]]


==Overview==
* Puffy face and loss of [[eyebrows]]
 
* [[Periorbital edema]]
 
* [[Macroglossia|Enlargement of the tongue]]


===Physical Examination===
* [[Diastolic blood pressure|Diastolic]] [[hypertension]]
====Appearance====
* The patient may be [[dehydrated]] and [[lethargic]].


====Vital Signs====
* [[Pleural Effusion|Pleural]] and [[Pericardial effusion|pericardial effusions]]
* [[Hypotension|Low blood pressure]] that falls further when standing ([[orthostatic hypotension]])
* [[Cardiovascular collapse]] may be present


====Skin====
* [[Ascites]]
* There can be tanning of the skin. [[Tanning]] of the skin that may be patchy or even all over the body. Characteristic sites of tanning are skin creases (e.g. of the hands) and the inside of the cheek ([[buccal mucosa]]).
* [[Vitiligo]] may also be present.
* Absence of axillary and pubic hair in females as a result of loss of adrenal [[androgens]].
* [[Pallor]] may be present.


====Neck====
* [[Galactorrhea]]
* [[Goitre]] may be present
|-
| 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==
{{Reflist|2}}
{{reflist|2}}
 
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Latest revision as of 21:30, 15 November 2017

Secondary adrenal insufficiency Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Adrenal insufficiency from other Diseases

Epidemiology and Demographics

Risk Factors

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Natural History, Complications and Prognosis

Diagnosis

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Physical Examination

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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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