Pituitary apoplexy physical examination

Patients with pituitary apoplexy appear ill and usually look tired. Physical examination of patients with pituitary apoplexy is usually remarkable for orthostatic hypotension, visual acuity and visual field defects, cranial nerve palsies, Horner syndrome, meningeal irritation, altered level of consciousness, severe mental status change, and other signs of hypopituitarism.

• Patients of hypopituitarism appear ill and usually look tired.^[1][2][3]

• Orthostatic hypotension

• Dry skin
• Pallor
• Loss of hair

• Visual acuity defects (52%) and visual field defects (64%) result from the upward expansion of the tumor. Superior expansion of the tumor causes dysfunction of the optic nerve and optic chiasm. The most common visual field defect is a bitemporal superior quadratic defect. Less commonly, optic tract involvement from a prefixed chiasm results in a contralateral homonymous hemianopia. Optic nerve compression from a postfixed chiasm is rare and may mimic optic neuritis with pain on eye movement, monocular visual acuity loss, and a central scotoma on visual field testing.^[4]
• Cranial nerve palsies (nerves III, IV, V, and VI). Lateral expansion of the pituitary adenoma into the cavernous sinus is usually presented. If consciousness is maintained, diplopia may be present. Of the cranial nerves: 
  • Cranial nerve III (oculomotor nerve) is involved most commonly, resulting in a unilateral dilated pupil, ptosis, and eye that is deviated inferiorly and laterally.
  • Cranial nerve IV (trochlear nerve) palsy typically manifests as vertical diplopia that worsens when the patient gazes in a direction opposite or tilts the head toward the direction of the affected eye.
  • Cranial nerve V (trigeminal nerve) involvement may produce facial pain or sensory loss.
  • Cranial nerve VI (abducent nerve) is least commonly involved, perhaps because of its sheltered position in the cavernous sinus. Its involvement produces horizontal diplopia, which results from an inability to abduct the involved eye.
• Horner syndrome may develop from damage to the sympathetic fibers. Hemispheric deficits may also develop.

• Signs of meningeal irritation: The hemorrhagic expansion may disrupt the dural covering of the pituitary, thus allowing blood to enter the subarachnoid space to produce meningeal irritation. Therefore, retro orbital headache is the most common presenting symptom in a conscious patient.^[5]
• Altered level of consciousness is due to compression of the internal carotid artery which may present a rapid downhill course.
• Severe mental status change is an indication for rapid neurosurgical decompression.
• Delayed reflexes

• Dyspnea
• Shortness of breath

• Bradycardia
• Atherosclerosis

• Rebound tenderness

• Muscle weakness
• Osteoporosis

• Hypogonadism (Micropenis)
• Erectile dysfunction

• Atrophy of limbs

Template:WH Template:WS