Pituitary Examination Component What to do/look for and rationale Wash hands Introduce self. Briefly explain purpose and obtain consent. Ask about pain before you begin. Ask for vitals. Weight. Short stature: failure of growth hormone secretion Pallor: due to anaemia or MSH Fine wrinkle skin or lack of body hair -> lack of gonadotropins Face and body habitus indicative of acromegaly: General Inspection Trans frontal scar Frontal bossing Molluscum fibrosum Proximal myopathy Spade like hands Multiple wrinkles around the face: Characteristics of gonadotropin deficiency Face In men feel for normal hair growth Gonadotropin deficiency Papillo edema Acromegaly Visual defects: Compression of the optic chiasm Eyes Bitemporal hemianopia “tunnel vision”. Cranial nerve III, IV and VI and first divisions of V examination Optic nerve atrophy on fundoscopy Due to an enlargement of the pituray which causes compression of the optic nerve. Wide spadelike fingers Due to soft and bony enlargement Acromegaly or Cushing’s disease Palmar erythema Increase metabolism due to: Acromegaly Hands Hyperthyroidism Cool peripheries Hypothyroidism Skin thickening -> best assessed from the back of the hands -> skin folds should be more than 1.8 mm. Acromegaly or Cushing’s syndrome Phalen tests for carpal tunnel syndrome due to median nerve compression Acromegaly Enlarged tongue -> cannot properly fit into the mouth Acromegaly Mouth Splayed and separated teeth Acromegaly Axilla: Look for skin tags -> acrochondrosis -> non-tender skin-coloured protrusions Arms Acanthosis nigricans Proximal myopathy Palpate behind the medial epicondyles for ulnar nerve thickening secondary to acromegaly Palpate the neck for thyroid enlargement and listen to voice enlargement Acromegaly Neck Hyperthyroidism -> goitre Pallor Decrease in nipple pigmentation Lactation from breasts in men and non-breastfeeding women Increased prolactin Chest Decreased body hair on the chest and the axilla Gonadotropin deficiency Cardiomegaly Acromegaly Look for hepatomegaly, splenomegaly and renal enlargement Abdomen Acromegaly or pituitary tumor Loss of pubic hair -> both men and women Genital region Testicular atrophy -> normal size tests should be 15 to 25 mL in volume. Gonadotropin deficiency Look for signs of OA Lower limbs Acromegaly Test for hung up jerks. Ankle reflexes Important sign of pituitary hypothyroidism Back Look for kyphosis Urine analysis Important bedside investigations to do Presence of glucose due to high GH level -> feature of acromegaly or pituitary adenoma (depending on which hormones are increased in production) Blood pressure Feature of acromegaly or hyperthyroidism or pituitary adenoma THESE ARE ESPECIALLY IMPORTANT FOR ACROMGEALY TO ASSESS FOR WHEN DETERMINING IF DISEASE IS ACTIVE OR NOT. Large number of skin tags Excessive sweating Note signs of active disease Presence of glycosuria Increasing visual field defects Enlarging goitre Hypertension