Pheochromocytoma physical examination: Difference between revisions
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==Overview== | ==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== | ||
Physical examination of patients with [[pheochromocytoma]] is usually remarkable for [[tachycardia]], [[hypertension]], and [[orthostatic hypotension]]. | |||
=== Appearance of the Patient === | === Appearance of the Patient === | ||
* Patients | * 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 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 [[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 | * 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 === | === 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]]. | * [[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.]] | * [[Tachypnea]] if [[malignant]] secondaries are found in the [[lung]]. [[Dyspnea]] occurs in patients with complicated [[heart failure]] and [[Cardiomyopathy|cardiomyopathy.]] | ||
* Rapid strong equal [[pulse]]. | * Rapid strong equal [[pulse]]. | ||
* High [[blood pressure]] with normal [[pulse pressure]]. | * High [[blood pressure]] with normal [[pulse pressure]]. | ||
* [[Hypotension]] occurs due to fluid contraction. | * [[Hypotension]] occurs due to fluid contraction. | ||
=== Skin === | === Skin === | ||
* [[Jaundice]] secondary to deranged [[liver]] function in case of [[metastasis]] to the [[liver]]. | * [[Jaundice]] secondary to deranged [[liver]] function in case of [[metastasis]] to the [[liver]]. | ||
=== | === HEENT=== | ||
* [[Facial flushing]]. | * [[Facial flushing]]. | ||
* [[Icterus|Scleral icterus]] in case of [[metastasis]] to the [[liver]]. | * [[Icterus|Scleral icterus]] in case of [[metastasis]] to the [[liver]]. | ||
| Line 53: | Line 55: | ||
=== Back === | === Back === | ||
* Point [[tenderness]] in [[MEN1]] patients with [[hyperparathyroidism]]. | * 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== | ||
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
- Patients with pheochromocytoma usually appear tired, weak, diaphoretic and anxious.[1]
- Patients may appear quite well if the disease is asymptomatic.
- Patients may appear flushed due to associated increase in erythropoietin secretion.[2]
- Patients may appear obese due to associated type 2 diabetes mellitus and Cushing's syndrome.[3]
Vital Signs
- Hyperthermia may be present [4]
- 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.
HEENT
- 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.
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. [10]
- Hyperreflexia [11]
- In case of acute stroke due to paroxysmal hypertension, the following may be seen:
- Corresponding cranial nerve deficit
- Unilateral/bilateral upper/lower extremity weakness
- Unilateral/bilateral sensory loss in the upper/lower extremity
- Bilateral tremor at rest
Extremities
References
- ↑ Bravo EL, Gifford RW (1993). "Pheochromocytoma". Endocrinol Metab Clin North Am. 22 (2): 329–41. PMID 8325290.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "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) - ↑ Manger WM, Davis SW, Chu DS (1979). "Autonomic hyperreflexia and its differentiation from pheochromocytoma". Arch Phys Med Rehabil. 60 (4): 159–61. PMID 475568.