Secondary adrenal insufficiency 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

• Patients with secondary adrenal insufficiency usually appear weak and fatigued.
• They may present with 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
• No dehydration

Skin

• Pallor may be present
• Bruises may be present
• No hyperpigmentation
• Alabaster-coloured 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

• S1 , soft and normal
• 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:

Hormonal deficiency	Finding
ACTH	Acute	Postural hypotension Tachycardia
	Chronic	Anorexia Weight loss No hyperpigmentation
TSH	Slow movement and slow speech Delayed relaxation of tendon reflexes Bradycardia Carotenemia Coarse skin Puffy face and loss of eyebrows Periorbital edema Enlargement of the tongue Diastolic hypertension Pleural and pericardial effusions Ascites Galactorrhea
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
Growth hormone	Children	Short stature
	Adults	Decreased sweating and impaired thermogenesis Reduced muscle mass and strength Fine facial wrinkles Increased central obesity

References

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