Mesenteric ischemia physical examination: Difference between revisions

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==Overview==
==Overview==
The presence of uncertain abdominal pain out of proportion to physical examination findings is diagnostic of mesenteric ischemia.
Physical examination of patients with [[Mesenteric ischemia|mesenteric]] ischemia can be normal in early stages or there may be mild [[Abdominal distension|abdominal]] [[distension]] in the absence of [[peritonitis]] which presents as [[rebound tenderness]] and [[Abdominal guarding|guarding]]. As the [[ischemia]] progresses to involve all the layers of the intestine (transmural [[infarction]]), abdomen becomes [[Abdominal distension|distended]], [[Peritoneum|peritoneal]] signs develop and [[bowel sounds]] become absent.  A feculent odor of the breath may also be noticed. Signs of [[dehydration]] and [[shock]] may also appear if not treated in time.


The presence of  on physical examination is highly suggestive of [disease name].
== Physical examination ==
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*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===
===Appearance of the Patient===
*Patients presenting with acute occlusive mesenteric ischemia are in acute distress.  
*Patients presenting with acute occlusive mesenteric ischemia are in acute [[distress]] while patients with chronic mesenteric ischemia may look malnourished due to [[sitophobia]] (fear of eating).  


===Vital Signs===
===Vital Signs===
*[[Tachycardia]] with irregular pulse
The following findings are present if the patient presents in a state of [[shock]] or hemodyanamic instability:<ref name="CarverVora2016">{{cite journal|last1=Carver|first1=Thomas W.|last2=Vora|first2=Ravi S.|last3=Taneja|first3=Amit|title=Mesenteric Ischemia|journal=Critical Care Clinics|volume=32|issue=2|year=2016|pages=155–171|issn=07490704|doi=10.1016/j.ccc.2015.11.001}}</ref>
*Tachypnea
*[[Tachycardia]] with irregular pulse in case o[[Atrial fibrillation|f atrial fibrillation]].
*Weak/bounding pulse
*[[Tachypnea]]


===Skin===
===Skin===


* [[Pallor]]
* [[Pallor]] is present in patients presenting with shock.  
 
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===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]]
*[[Jugular venous distension]] in case of congestive heart failure.
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Carotid bruits]] may be auscultated unilaterally / bilaterally using the bell of the stethoscope in patients having [[atherosclerosis]].
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]
 
===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===
===Heart===
*Chest tenderness upon palpation
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] and [[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] is loud if the patient presents in [[shock]].
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heart sounds#Third heart sound S3|S3]] is present in case of [[Congestive heart failure|congestive]] heart failure.
*[[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 shows the following findings in later stages of ischemia when transmural infarction has occured:<ref name="CudnikDarbha2013">{{cite journal|last1=Cudnik|first1=Michael T.|last2=Darbha|first2=Subrahmanyam|last3=Jones|first3=Janice|last4=Macedo|first4=Julian|last5=Stockton|first5=Sherrill W.|last6=Hiestand|first6=Brian C.|last7=Jones|first7=Alan E.|title=The Diagnosis of Acute Mesenteric Ischemia: A Systematic Review and Meta-analysis|journal=Academic Emergency Medicine|volume=20|issue=11|year=2013|pages=1087–1100|issn=10696563|doi=10.1111/acem.12254}}</ref>
*[[Abdominal distention]]  
*[[Abdominal distention]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*Generalized [[Abdominal tenderness]]
*[[Rebound tenderness]] (positive Blumberg sign)
*[[Rebound tenderness]]  
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*[[Abdominal guarding|Guarding]] may be present
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*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===
===Extremities===
*[[Clubbing]]
*[[Cyanosis]] can be present in later stage of [[shock]].
*[[Cyanosis]]  
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==

Latest revision as of 20:08, 19 January 2018

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

Overview

Physical examination of patients with mesenteric ischemia can be normal in early stages or there may be mild abdominal distension in the absence of peritonitis which presents as rebound tenderness and guarding. As the ischemia progresses to involve all the layers of the intestine (transmural infarction), abdomen becomes distended, peritoneal signs develop and bowel sounds become absent. A feculent odor of the breath may also be noticed. Signs of dehydration and shock may also appear if not treated in time.

Physical examination

Appearance of the Patient

  • Patients presenting with acute occlusive mesenteric ischemia are in acute distress while patients with chronic mesenteric ischemia may look malnourished due to sitophobia (fear of eating).

Vital Signs

The following findings are present if the patient presents in a state of shock or hemodyanamic instability:[1]

Skin

  • Pallor is present in patients presenting with shock.

Neck

Heart

Abdomen

Abdominal examination shows the following findings in later stages of ischemia when transmural infarction has occured:[2]

Extremities

References

  1. ↑ Carver, Thomas W.; Vora, Ravi S.; Taneja, Amit (2016). "Mesenteric Ischemia". Critical Care Clinics. 32 (2): 155–171. doi:10.1016/j.ccc.2015.11.001. ISSN 0749-0704.
  2. ↑ Cudnik, Michael T.; Darbha, Subrahmanyam; Jones, Janice; Macedo, Julian; Stockton, Sherrill W.; Hiestand, Brian C.; Jones, Alan E. (2013). "The Diagnosis of Acute Mesenteric Ischemia: A Systematic Review and Meta-analysis". Academic Emergency Medicine. 20 (11): 1087–1100. doi:10.1111/acem.12254. ISSN 1069-6563.
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