Irritable bowel syndrome physical examination: Difference between revisions

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{{Irritable bowel syndrome}}
{{Irritable bowel syndrome}}
{{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].
Patients with [[Irritable bowel syndrome|irritable bowel syndrome]] usually appear normal on [[Physical examination|physical exam]]. [[Physical examination]] of patients with [[Irritable bowel syndrome|IBS]] may elicit [[Tenderness (medicine)|abdominal tenderness]] in some patients. A [[Rectal examination|digital rectal examination]] must be performed in all patients to rule out [[rectal]] growths, blood in [[Human feces|stool]] and evaluate for dyssynergic [[defecation]] (where paradoxical contraction of the rectal [[sphincter]] occurs on straining, leading to [[constipation]]). Physical findings such as [[fever]], [[abdominal mass]], [[hepatosplenomegaly]], [[lymph node]] enlargement, [[weight loss]], [[Peritoneum|peritoneal]] signs and [[ascites]] are absent in [[Irritable bowel syndrome|IBS]] and help rule out organic causes.   
 
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==
===Appearance of the patient===
*Patients with [[Irritable bowel syndrome|irritable bowel syndrome]] usually appear normal/mildly distressed. Physical exam is normal in most patients.<ref name="pmid27492916">{{cite journal |vauthors=Bharucha AE, Chakraborty S, Sletten CD |title=Common Functional Gastroenterological Disorders Associated With Abdominal Pain |journal=Mayo Clin. Proc. |volume=91 |issue=8 |pages=1118–32 |year=2016 |pmid=27492916 |pmc=4985027 |doi=10.1016/j.mayocp.2016.06.003 |url=}}</ref><ref name="pmid21872090">{{cite journal |vauthors=Malone MA |title=Irritable bowel syndrome |journal=Prim. Care |volume=38 |issue=3 |pages=433–47; viii |year=2011 |pmid=21872090 |doi=10.1016/j.pop.2011.05.003 |url=}}</ref><ref name="pmid19151451">{{cite journal |vauthors=Abdullah M |title=Irritable bowel syndrome: current review on pathophysiology and diagnotic aspects |journal=Acta Med Indones |volume=40 |issue=4 |pages=218–25 |year=2008 |pmid=19151451 |doi= |url=}}</ref><ref name="pmid17606954">{{cite journal |vauthors=Wilson JF |title=In the clinic. Irritable bowel syndrome |journal=Ann. Intern. Med. |volume=147 |issue=1 |pages=ITC7–1–ITC7–16 |year=2007 |pmid=17606954 |doi=10.7326/0003-4819-147-1-200707030-01007 |url=}}</ref><ref name="pmid16455728">{{cite journal |vauthors=Agrawal A, Whorwell PJ |title=Irritable bowel syndrome: diagnosis and management |journal=BMJ |volume=332 |issue=7536 |pages=280–3 |year=2006 |pmid=16455728 |pmc=1360402 |doi=10.1136/bmj.332.7536.280 |url=}}</ref>


*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
===Vital signs===
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].
 
===Vital Signs===


*High-grade / low-grade fever
*Afebrile
*[[Hypothermia]] / hyperthermia may be present
*Regular [[pulse]]
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*Normal [[blood pressure]]  
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Normal [[respiratory rate]]  
*Tachypnea / bradypnea
*IBS-diarrhea patients with [[dehydration]]/[[hypovolemia]] as a complication develop:<ref name="pmid10086438">{{cite journal |vauthors=McGee S, Abernethy WB, Simel DL |title=The rational clinical examination. Is this patient hypovolemic? |journal=JAMA |volume=281 |issue=11 |pages=1022–9 |year=1999 |pmid=10086438 |doi= |url=}}</ref>
*Kussmal respirations may be present in _____ (advanced disease state)
**[[tachycardia]]
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
**low [[blood pressure]]  
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]
**[[Orthostatic hypotension|postural hypotension]]


===Skin===
===Skin===
*[[Cyanosis]]
* Skin turgor is normal in most patients
*[[Jaundice]]
* [[Irritable bowel syndrome|IBS]]-[[diarrhea]] patients with [[dehydration]]/[[hypovolemia]] as a complication develop:<ref name="pmid10086438">{{cite journal |vauthors=McGee S, Abernethy WB, Simel DL |title=The rational clinical examination. Is this patient hypovolemic? |journal=JAMA |volume=281 |issue=11 |pages=1022–9 |year=1999 |pmid=10086438 |doi= |url=}}</ref>
* [[Pallor]]
** decreased skin turgor
* Bruises
** dryness of tongue and oral [[Mucous membrane|mucosa]] due to decreased [[Salivary gland|salivary]] secretions
 
<gallery widths=150px>
 
UploadedImage-01.jpg | Description {{dermref}}
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===
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Asymmetric chest expansion / Decreased chest expansion
* Normal chest expansion
*Lungs are hypo/hyperresonant
*Normal [[Vesicular breathing|vesicular]] breath sounds in B/L lung fields
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Normal [[tactile fremitus]]
*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===
===Heart===
*Chest tenderness upon palpation
*[[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]] normal
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*No additional sounds
*[[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 distention]]
Findings on abdominal examination are as follows:<ref name="pmid19521341">{{cite journal |vauthors=Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM |title=An evidence-based position statement on the management of irritable bowel syndrome |journal=Am. J. Gastroenterol. |volume=104 Suppl 1 |issue= |pages=S1–35 |year=2009 |pmid=19521341 |doi=10.1038/ajg.2008.122 |url=}}</ref><ref name="pmid10588169">{{cite journal |vauthors=Schmulson MW, Chang L |title=Diagnostic approach to the patient with irritable bowel syndrome |journal=Am. J. Med. |volume=107 |issue=5A |pages=20S–26S |year=1999 |pmid=10588169 |doi= |url=}}</ref><ref name="pmid4023607">{{cite journal |vauthors=Svendsen JH, Munck LK, Andersen JR |title=Irritable bowel syndrome--prognosis and diagnostic safety. A 5-year follow-up study |journal=Scand. J. Gastroenterol. |volume=20 |issue=4 |pages=415–8 |year=1985 |pmid=4023607 |doi= |url=}}</ref>
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
* Examination results are usually normal
*[[Rebound tenderness]] (positive Blumberg sign)
* [[Abdominal distention]] may be present
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*[[Abdominal tenderness]] may be elicited in different quadrants
*Guarding may be present
*Absence of abdominal masses, [[Splenomegaly|hepatospleenomegaly]]
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Normal [[Intestine|bowel]] sounds
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
*A pelvic/adnexal mass may be palpated
*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===
=== Rectal exam ===
*[[Clubbing]]  
*IBS patients usually have a normal [[rectal]] exam.To rule out organic causes of [[constipation]] and [[diarrhea]], rectal exam must be done in patients to evaluate for: <ref name="pmid16803612">{{cite journal |vauthors=Whitehead WE, Palsson OS, Feld AD, Levy RL, VON Korff M, Turner MJ, Drossman DA |title=Utility of red flag symptom exclusions in the diagnosis of irritable bowel syndrome |journal=Aliment. Pharmacol. Ther. |volume=24 |issue=1 |pages=137–46 |year=2006 |pmid=16803612 |doi=10.1111/j.1365-2036.2006.02956.x |url=}}</ref><ref name="pmid6724251">{{cite journal |vauthors=Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W |title=A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease |journal=Gastroenterology |volume=87 |issue=1 |pages=1–7 |year=1984 |pmid=6724251 |doi= |url=}}</ref><ref name="pmid18397419">{{cite journal |vauthors=Talley NJ |title=How to do and interpret a rectal examination in gastroenterology |journal=Am. J. Gastroenterol. |volume=103 |issue=4 |pages=820–2 |year=2008 |pmid=18397419 |doi=10.1111/j.1572-0241.2008.01832.x |url=}}</ref><ref name="pmid20656061">{{cite journal |vauthors=Tantiphlachiva K, Rao P, Attaluri A, Rao SS |title=Digital rectal examination is a useful tool for identifying patients with dyssynergia |journal=Clin. Gastroenterol. Hepatol. |volume=8 |issue=11 |pages=955–60 |year=2010 |pmid=20656061 |doi=10.1016/j.cgh.2010.06.031 |url=}}</ref><ref name="pmid26032152">{{cite journal |vauthors=Soh JS, Lee HJ, Jung KW, Yoon IJ, Koo HS, Seo SY, Lee S, Bae JH, Lee HS, Park SH, Yang DH, Kim KJ, Ye BD, Byeon JS, Yang SK, Kim JH, Myung SJ |title=The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence |journal=Am. J. Gastroenterol. |volume=110 |issue=8 |pages=1197–204 |year=2015 |pmid=26032152 |doi=10.1038/ajg.2015.153 |url=}}</ref>
*[[Cyanosis]]  
** presence of [[stool]] and its consistency
*Pitting/non-pitting [[edema]] of the upper/lower extremities
**[[Rectal]] tenderness
*Muscle atrophy
**Strictures
*Fasciculations in the upper/lower extremity
** Masses
**rectal [[prolapse]]
** [[Fistula|Fistulas]]
** [[Hemorrhoid|Hemorrhoids]]  
** [[Abscess|Abscesses]]  
** [[Fissure|Fissures]]
**impaired [[sphincter]] function due to a [[Neurology|neurologic]] disorder
**responses of the [[puborectalis]] and [[External anal sphincter|external anal sphincter muscles]] while straining to rule out dyssynergic [[defecation]]


==References==
==References==

Latest revision as of 14:48, 4 December 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 irritable bowel syndrome usually appear normal on physical exam. Physical examination of patients with IBS may elicit abdominal tenderness in some patients. A digital rectal examination must be performed in all patients to rule out rectal growths, blood in stool and evaluate for dyssynergic defecation (where paradoxical contraction of the rectal sphincter occurs on straining, leading to constipation). Physical findings such as fever, abdominal mass, hepatosplenomegaly, lymph node enlargement, weight loss, peritoneal signs and ascites are absent in IBS and help rule out organic causes.   

Physical Examination

Appearance of the patient

Vital signs

Skin

Lungs

Heart

  • S1 /S2 normal
  • No additional sounds

Abdomen

Findings on abdominal examination are as follows:[7][8][9]

Rectal exam

References

  1. ↑ Bharucha AE, Chakraborty S, Sletten CD (2016). "Common Functional Gastroenterological Disorders Associated With Abdominal Pain". Mayo Clin. Proc. 91 (8): 1118–32. doi:10.1016/j.mayocp.2016.06.003. PMC 4985027. PMID 27492916.
  2. ↑ Malone MA (2011). "Irritable bowel syndrome". Prim. Care. 38 (3): 433–47, viii. doi:10.1016/j.pop.2011.05.003. PMID 21872090.
  3. ↑ Abdullah M (2008). "Irritable bowel syndrome: current review on pathophysiology and diagnotic aspects". Acta Med Indones. 40 (4): 218–25. PMID 19151451.
  4. ↑ Wilson JF (2007). "In the clinic. Irritable bowel syndrome". Ann. Intern. Med. 147 (1): ITC7–1–ITC7–16. doi:10.7326/0003-4819-147-1-200707030-01007. PMID 17606954.
  5. ↑ Agrawal A, Whorwell PJ (2006). "Irritable bowel syndrome: diagnosis and management". BMJ. 332 (7536): 280–3. doi:10.1136/bmj.332.7536.280. PMC 1360402. PMID 16455728.
  6. ↑ 6.0 6.1 McGee S, Abernethy WB, Simel DL (1999). "The rational clinical examination. Is this patient hypovolemic?". JAMA. 281 (11): 1022–9. PMID 10086438.
  7. ↑ Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM (2009). "An evidence-based position statement on the management of irritable bowel syndrome". Am. J. Gastroenterol. 104 Suppl 1: S1–35. doi:10.1038/ajg.2008.122. PMID 19521341.
  8. ↑ Schmulson MW, Chang L (1999). "Diagnostic approach to the patient with irritable bowel syndrome". Am. J. Med. 107 (5A): 20S–26S. PMID 10588169.
  9. ↑ Svendsen JH, Munck LK, Andersen JR (1985). "Irritable bowel syndrome--prognosis and diagnostic safety. A 5-year follow-up study". Scand. J. Gastroenterol. 20 (4): 415–8. PMID 4023607.
  10. ↑ Whitehead WE, Palsson OS, Feld AD, Levy RL, VON Korff M, Turner MJ, Drossman DA (2006). "Utility of red flag symptom exclusions in the diagnosis of irritable bowel syndrome". Aliment. Pharmacol. Ther. 24 (1): 137–46. doi:10.1111/j.1365-2036.2006.02956.x. PMID 16803612.
  11. ↑ Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W (1984). "A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease". Gastroenterology. 87 (1): 1–7. PMID 6724251.
  12. ↑ Talley NJ (2008). "How to do and interpret a rectal examination in gastroenterology". Am. J. Gastroenterol. 103 (4): 820–2. doi:10.1111/j.1572-0241.2008.01832.x. PMID 18397419.
  13. ↑ Tantiphlachiva K, Rao P, Attaluri A, Rao SS (2010). "Digital rectal examination is a useful tool for identifying patients with dyssynergia". Clin. Gastroenterol. Hepatol. 8 (11): 955–60. doi:10.1016/j.cgh.2010.06.031. PMID 20656061.
  14. ↑ Soh JS, Lee HJ, Jung KW, Yoon IJ, Koo HS, Seo SY, Lee S, Bae JH, Lee HS, Park SH, Yang DH, Kim KJ, Ye BD, Byeon JS, Yang SK, Kim JH, Myung SJ (2015). "The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence". Am. J. Gastroenterol. 110 (8): 1197–204. doi:10.1038/ajg.2015.153. PMID 26032152.

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