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==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 anal fissure usually appear in pain. Physical examination of patients with anal fissure is usually remarkable for painful skin laceration, skin tags in the chronic anal fissure. A tear is usually seen in the posterior part of anal canal (90)% and in anterior or middle part (10%). Patient usually resists use of anoscope due to the pain. Acute anal fissures appear as fresh laceration while chronic have raised margins.
 
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].


==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 anal fissure is usually remarkable for painful skin laceration, skin tags in the chronic anal fissure.
*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 with [disease name] usually appear [general appearance].  
*Patients with anal fissure usually appear in pain.


===Vital Signs===
===Vital Signs===
 
*[[Tachycardia]] with regular pulse (in pain).
*High-grade / low-grade fever
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[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===
* Skin examination of patients with [disease name] is usually normal.
*Skin examination of patients with anal fissure:
OR
**Perianal skin can be inflamed.
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* HEENT examination of patients with anal fissure is usually normal.
OR
* 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===
* Neck examination of patients with [disease name] is usually normal.
* Neck examination of patients with anal fissure is usually normal.
OR
*[[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===
* Pulmonary examination of patients with [disease name] is usually normal.
* Pulmonary examination of patients with anal fissure is usually normal.
OR
* 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===
* Cardiovascular examination of patients with [disease name] is usually normal.
* Cardiovascular examination of patients with anal fissure is usually normal.
OR
*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 of patients with [disease name] is usually normal.
* Abdominal examination of patients with anal fissure is usually normal.
 


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with anal fissure is usually normal.
OR
===Genitourinary===
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary=== {| align="right"
* Genitourinary examination of patients with anal fissure is usually normal.
|[[File:Anal fissure 2.jpg|thumb|250px|By Bernardo Gui - Own work, Public Domain<ref> https://commons.wikimedia.org/w/index.php?curid=8885756</ref>]]
===Local/anal examination===
{| align="right"
|[[File:Anal fissure 2.jpg|thumb|250px|By Bernardo Gui - Own work, Public Domain<ref>https://commons.wikimedia.org/w/index.php?curid=8885756</ref>]]
|[[File:Anal fissure.jpg|thumb|250px|By Jonathanlund - Own work, Public Domain<ref>https://commons.wikimedia.org/w/index.php?curid=5148617</ref>]]
|}
|}
* Genitourinary examination of patients with [disease name] is usually normal.
*The examination should be done when the patient is lying in the lateral position. The digital rectal examination is contraindicated in many patients considering the amount of pain.<ref name="pmid15812586">{{cite journal |vauthors=Jones OM, Ramalingam T, Lindsey I, Cunningham C, George BD, Mortensen NJ |title=Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable |journal=Dis. Colon Rectum |volume=48 |issue=2 |pages=349–52 |year=2005 |pmid=15812586 |doi=10.1007/s10350-004-0753-2 |url=}}</ref>
OR
*[[Anoscopy]]/[[proctoscopy]] can be done with topical anesthesia with [[lidocaine]] gel to examine, and rule out internal [[hemorrhoids]].<ref name="pmid29132530">{{cite journal |vauthors=Davies D, Bailey J |title=Diagnosis and Management of Anorectal Disorders in the Primary Care Setting |journal=Prim. Care |volume=44 |issue=4 |pages=709–720 |year=2017 |pmid=29132530 |doi=10.1016/j.pop.2017.07.012 |url=}}</ref><ref name="pmid27041801">{{cite journal |vauthors=Schlichtemeier S, Engel A |title=Anal fissure |journal=Aust Prescr |volume=39 |issue=1 |pages=14–7 |year=2016 |pmid=27041801 |pmc=4816871 |doi=10.18773/austprescr.2016.007 |url=}}</ref>
*A pelvic/adnexal mass may be palpated
====Inspection====
*Inflamed mucosa
*On inspection, there is a breach in the skin. A laceration can be seen usually in the posterior midline in 90% of patients while in the remaining 10% of patients in the anterior midline.
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
*Acute anal fissures appear as fresh laceration while chronic have raised margins.<ref name="pmid27041801" />
 
*Chronic anal fissures may have a skin tag also.
===Local/anal examination===
 


====Palpation====
*Anal fissures are usually exquisitely [[Tenderness (medicine)|tender]] and the patient is scared to touch them or let physician examine.
*Palpation shows tear in the anoderm with exposed internal sphincter (with retraction of the [[buttocks]]).<ref>{{cite book | last = Bope | first = Edward | title = Conn's current therapy 2018 | publisher = Elsevier | location = Philadelphia | year = 2018 | isbn = 978-0323527699 }}</ref>


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
* Neuromuscular examination of patients with anal fissure is usually normal.
OR
*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===
* Extermities examination of patients with [disease name] is usually normal.
* Extremities examination of patients with anal fissure is usually normal.<br>
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
 
 


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 20:24, 29 July 2020

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

Overview

Patients with anal fissure usually appear in pain. Physical examination of patients with anal fissure is usually remarkable for painful skin laceration, skin tags in the chronic anal fissure. A tear is usually seen in the posterior part of anal canal (90)% and in anterior or middle part (10%). Patient usually resists use of anoscope due to the pain. Acute anal fissures appear as fresh laceration while chronic have raised margins.

Physical Examination

  • Physical examination of patients with anal fissure is usually remarkable for painful skin laceration, skin tags in the chronic anal fissure.

Appearance of the patient

  • Patients with anal fissure usually appear in pain.

Vital Signs

Skin

  • Skin examination of patients with anal fissure:
    • Perianal skin can be inflamed.

HEENT

  • HEENT examination of patients with anal fissure is usually normal.

Neck

  • Neck examination of patients with anal fissure is usually normal.

Lungs

  • Pulmonary examination of patients with anal fissure is usually normal.

Heart

  • Cardiovascular examination of patients with anal fissure is usually normal.

Abdomen

  • Abdominal examination of patients with anal fissure is usually normal.

Back

  • Back examination of patients with anal fissure is usually normal.

Genitourinary

  • Genitourinary examination of patients with anal fissure is usually normal.

Local/anal examination

By Bernardo Gui - Own work, Public Domain[1]
By Jonathanlund - Own work, Public Domain[2]
  • The examination should be done when the patient is lying in the lateral position. The digital rectal examination is contraindicated in many patients considering the amount of pain.[3]
  • Anoscopy/proctoscopy can be done with topical anesthesia with lidocaine gel to examine, and rule out internal hemorrhoids.[4][5]

Inspection

  • On inspection, there is a breach in the skin. A laceration can be seen usually in the posterior midline in 90% of patients while in the remaining 10% of patients in the anterior midline.
  • Acute anal fissures appear as fresh laceration while chronic have raised margins.[5]
  • Chronic anal fissures may have a skin tag also.

Palpation

  • Anal fissures are usually exquisitely tender and the patient is scared to touch them or let physician examine.
  • Palpation shows tear in the anoderm with exposed internal sphincter (with retraction of the buttocks).[6]

Neuromuscular

  • Neuromuscular examination of patients with anal fissure is usually normal.

Extremities

  • Extremities examination of patients with anal fissure is usually normal.

References

  1. ↑ https://commons.wikimedia.org/w/index.php?curid=8885756
  2. ↑ https://commons.wikimedia.org/w/index.php?curid=5148617
  3. ↑ Jones OM, Ramalingam T, Lindsey I, Cunningham C, George BD, Mortensen NJ (2005). "Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable". Dis. Colon Rectum. 48 (2): 349–52. doi:10.1007/s10350-004-0753-2. PMID 15812586.
  4. ↑ Davies D, Bailey J (2017). "Diagnosis and Management of Anorectal Disorders in the Primary Care Setting". Prim. Care. 44 (4): 709–720. doi:10.1016/j.pop.2017.07.012. PMID 29132530.
  5. ↑ 5.0 5.1 Schlichtemeier S, Engel A (2016). "Anal fissure". Aust Prescr. 39 (1): 14–7. doi:10.18773/austprescr.2016.007. PMC 4816871. PMID 27041801.
  6. ↑ Bope, Edward (2018). Conn's current therapy 2018. Philadelphia: Elsevier. ISBN 978-0323527699.

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