Pheochromocytoma physical examination

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 of patients with pheochromocytoma is usually remarkable for tachycardia, hypertension, and orthostatic hypotension.

• 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]

• 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.

• Jaundice secondary to deranged liver function in case of metastasis to the liver.

• Facial flushing.
• Scleral icterus in case of metastasis to the liver.
• MEN2 patients associated with mucosal neuromas show multiple lips and tongue neuromas.

• 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]

• Asymmetric chest expansion / decreased chest expansion if malignant secondaries are found in the lung.

• 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.

• 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]

• Point tenderness in MEN1 patients with hyperparathyroidism.

• Genitourinary examination of patients with pheochromocytoma is usually normal.

• 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

• Bilateral generalized tremors