Pancreatic cancer physical examination: Difference between revisions

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{{Pancreatic cancer}}
{{Pancreatic cancer}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{Cherry}}


==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
[[Patient|Patients]] with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with [[Medical sign|signs]] of [[malnutrition]]. Patients mostly present with [[Palpation|palpable]] [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatospleenomegaly]] and [[Medical sign|signs]] of [[metastasis]] in advanced stages. These [[Medical sign|signs]] of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), [[Palpation|palpable]] periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area.  
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
==Physical Examination==
==Physical Examination==


*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*Physical examination of patients with [[pancreatic cancer]] is usually remarkable for: [[epigastric]] [[tenderness]], [[jaundice]], and [[Palpation|palpable]] intra abdominal mass.
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') on physical examination is diagnostic of [[metastasis]].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
*The presence of [[ascites]] and a palpable, non tender [[Gallbladder|gall bladder]] on physical examination is a common finding in [[pancreatic cancer]] patients.


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
Patients with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with signs of [[malnutrition]]. Patients mostly present with palpable [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatosplenomegaly]] and signs of [[metastasis]] in advanced stages. These signs of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area.


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
*Regular [[pulse]]
*[[Hypothermia]] / hyperthermia may be present
*Normal [[blood pressure]]
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*Normal body temperature
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
*[[Cyanosis]]  
Skin findings are as follows: <ref name="pmid4005804">{{cite journal |vauthors=Kalser MH, Barkin J, MacIntyre JM |title=Pancreatic cancer. Assessment of prognosis by clinical presentation |journal=Cancer |volume=56 |issue=2 |pages=397–402 |year=1985 |pmid=4005804 |doi= |url=}}</ref><ref name="pmid15522652">{{cite journal |vauthors=Khorana AA, Fine RL |title=Pancreatic cancer and thromboembolic disease |journal=Lancet Oncol. |volume=5 |issue=11 |pages=655–63 |year=2004 |pmid=15522652 |doi=10.1016/S1470-2045(04)01606-7 |url=}}</ref><ref name="pmid3958764">{{cite journal |vauthors=Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G |title=Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center |journal=J. Clin. Oncol. |volume=4 |issue=4 |pages=509–14 |year=1986 |pmid=3958764 |doi=10.1200/JCO.1986.4.4.509 |url=}}</ref><ref name="pmid1330387">{{cite journal |vauthors=Ostlere LS, Branfoot AC, Staughton RC |title=Cicatricial pemphigoid and carcinoma of the pancreas |journal=Clin. Exp. Dermatol. |volume=17 |issue=1 |pages=67–8 |year=1992 |pmid=1330387 |doi= |url=}}</ref><ref name="pmid3164230">{{cite journal |vauthors=Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T |title=Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients |journal=Cancer |volume=62 |issue=1 |pages=135–41 |year=1988 |pmid=3164230 |doi= |url=}}</ref>
*[[Jaundice]]
*[[Jaundice]]: Yellowish discoloration of [[skin]], [[sclera]]
* [[Pallor]]
**Associated with [[Palpation|palpable]], non-tender and distended [[gallbladder]] at the right costal margin ([[Courvoisier's law|Courvoisier's sign]])<ref name="pmid19190960">{{cite journal |vauthors=Fitzgerald JE, White MJ, Lobo DN |title=Courvoisier's gallbladder: law or sign? |journal=World J Surg |volume=33 |issue=4 |pages=886–91 |year=2009 |pmid=19190960 |doi=10.1007/s00268-008-9908-y |url=}}</ref> 
* Bruises
**[[Excoriation|Excoriations]] of the [[skin]] from unrelenting [[Itch|pruritus]] 
**Darkening of the [[urine]] 
** [[Acholic stools|Acholic]] [[Human feces|stools]]
* [[Pallor]] ±
* [[Skin]] manifestations may include:
** [[Bullous pemphigoid]]
** [[Mucous membrane pemphigoid|Cicatricial pemphigoid]]
** [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]])
** [[Panniculitis|Pancreatic panniculitis]]:
*** Associated with [[Acinar cell|acinar cell variant]] of [[pancreatic cancer]]
*** Located mostly on the legs
*** Appears as an [[Erythema|erythematous]] [[Subcutaneous tissue|subcutaneous]] area of [[Nodule (medicine)|nodular]] [[fat necrosis]]
The following picture depicts [[bullous pemphigoid]] [[Lesion|lesions]] in a [[patient]]:


<gallery widths=150px>
[[Image:Pancreatic_cancer_-_Bullous_pemphgoid.jpg|thumb|350px|center|CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42563781]]


UploadedImage-01.jpg | Description {{dermref}}
{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>
 
===HEENT===
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
*[[Jugular venous distension]]
*Signs of [[Metastasis|metastatic disease]] include: <ref name="pmid9490607">{{cite journal |vauthors=Galvañ VG |title=Sister Mary Joseph's nodule |journal=Ann. Intern. Med. |volume=128 |issue=5 |pages=410 |year=1998 |pmid=9490607 |doi= |url=}}</ref>
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
**Left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]])
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
**Palpable periumbilical mass (''Sister Mary Joseph's node'')  
*[[Thyromegaly]] / thyroid nodules
**[[Metastasis|Metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'')
*[[Hepatojugular reflux]]
**Involvement of other [[Lymph node|nodes]] in the [[cervical]] area
 
===Lungs===
* Asymmetric chest expansion / Decreased chest expansion
*Lungs are hypo/hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
 
===Heart===
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope


===Abdomen===
===Abdomen===
Abdominal examination is as follows: <ref name="pmid8780535">{{cite journal |vauthors=Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T |title=Clinicopathologic features of small pancreatic adenocarcinoma. A collective study |journal=Cancer |volume=78 |issue=5 |pages=986–90 |year=1996 |pmid=8780535 |doi=10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A |url=}}</ref><ref name="pmid3942423">{{cite journal |vauthors=Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R |title=Collective review of small carcinomas of the pancreas |journal=Ann. Surg. |volume=203 |issue=1 |pages=77–81 |year=1986 |pmid=3942423 |pmc=1251042 |doi= |url=}}</ref><ref name="pmid11075985">{{cite journal |vauthors=Mujica VR, Barkin JS, Go VL |title=Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants |journal=Pancreas |volume=21 |issue=4 |pages=329–32 |year=2000 |pmid=11075985 |doi= |url=}}</ref>
*[[Abdominal distention]]  
*[[Abdominal distention]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Abdominal tenderness]]:
*[[Rebound tenderness]] (positive Blumberg sign)
**Site: [[tenderness]] in [[Epigastric|mid epigastric]] region 
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
**Onset: insidious 
*Guarding may be present
**Character: gnawing, visceral quality 
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
**Radiation- mid/lower back due to [[tumor]] invasion of the [[Retroperitoneum|retroperitoneal]] [[Splanchnic nerve|splanchnic nerve plexus]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
**Relieving factors: relieved on lying down in a curled or [[Fetus|fetal]] position may improve the pain 
 
**Aggravating factors: worse on lying supine or eating 
===Back===
**Timing: intermittent 
*Point tenderness over __ vertebrae (e.g. L3-L4)
**Severity- mild-moderate, worse at night
*Sacral edema
*An [[abdominal mass]] may be palpable in the epigastrium.
*Costovertebral angle tenderness bilaterally/unilaterally
*[[Hepatomegaly]] may arise from liver [[metastasis]]
*Buffalo hump
*[[splenomegaly]] may arise from portal vein obstruction
*[[hepatosplenomegaly]]
*Fluid thrill and dullness to [[percussion]] may be present due to [[ascites]]


===Genitourinary===
===Genitourinary===
*A pelvic/adnexal mass may be palpated
*In advanced stages of [[pancreatic cancer]], [[Metastasis|metastatic]] palpable mass may be present in the [[rectal]] pouch.(''Blumer's shelf'')
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Glasgow coma scale is ___ / 15
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)
 
===Extremities===
*[[Clubbing]]  
*[[Cyanosis]]  
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==
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{{WS}}
{{WS}}
[[Category: Gastroenterology]]
[[Category: Gastroenterology]]
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Surgery]]
[[Category:Gastroenterology]]

Latest revision as of 15:03, 27 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatospleenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.

Physical Examination

Appearance of the Patient

Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatosplenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.

Vital Signs

Skin

Skin findings are as follows: [1][2][3][4][5]

The following picture depicts bullous pemphigoid lesions in a patient:

CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42563781

{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}

Neck

Abdomen

Abdominal examination is as follows: [8][9][10]

Genitourinary

References

  1. Kalser MH, Barkin J, MacIntyre JM (1985). "Pancreatic cancer. Assessment of prognosis by clinical presentation". Cancer. 56 (2): 397–402. PMID 4005804.
  2. Khorana AA, Fine RL (2004). "Pancreatic cancer and thromboembolic disease". Lancet Oncol. 5 (11): 655–63. doi:10.1016/S1470-2045(04)01606-7. PMID 15522652.
  3. Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G (1986). "Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center". J. Clin. Oncol. 4 (4): 509–14. doi:10.1200/JCO.1986.4.4.509. PMID 3958764.
  4. Ostlere LS, Branfoot AC, Staughton RC (1992). "Cicatricial pemphigoid and carcinoma of the pancreas". Clin. Exp. Dermatol. 17 (1): 67–8. PMID 1330387.
  5. Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T (1988). "Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients". Cancer. 62 (1): 135–41. PMID 3164230.
  6. Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
  7. Galvañ VG (1998). "Sister Mary Joseph's nodule". Ann. Intern. Med. 128 (5): 410. PMID 9490607.
  8. Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T (1996). "Clinicopathologic features of small pancreatic adenocarcinoma. A collective study". Cancer. 78 (5): 986–90. doi:10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A. PMID 8780535.
  9. Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R (1986). "Collective review of small carcinomas of the pancreas". Ann. Surg. 203 (1): 77–81. PMC 1251042. PMID 3942423.
  10. Mujica VR, Barkin JS, Go VL (2000). "Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants". Pancreas. 21 (4): 329–32. PMID 11075985.

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