Pancreatic fistula physical examination: Difference between revisions

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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 [[Pancreatic fistula|pancreatic fistulas]] usually appear normal and in some they appear [[malnourished]]. Physical examination of patients with [[Pancreatic fistula|pancreatic fistulas]] is usually remarkable for [[infection]], [[dyspnea]], [[pleuritic chest pain]] and [[ascites]].
 
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 internal pancreatic fistulas is usually normal or asymptomatic, on the other hand patients with external pancreatic fistulas can present with drainage of fluid.
Physical examination of patients with internal [[Pancreatic fistula|pancreatic fistulas]] is usually normal or [[asymptomatic]], on the other hand patients with external [[Pancreatic fistula|pancreatic fistulas]] can present with drainage of fluid.
 
OR
 
Physical examination of patients with [disease name] is usually remarkable for [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].


===Appearance of the Patient===
===Appearance of the Patient===


*Patients with pancreatic fistulas usually appear normal.
*Most of the patients with [[Pancreatic fistula|pancreatic fistulas]] usually appear normal, but some might show the following the features:
**[[Dehydration]]
**[[Weight loss]] from [[malnourishment]]


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


*High-grade / low-grade fever
*Patients with [[Pancreatic fistula|pancreatic fistulas]] may present with [[fever]] when there is an [[infection]].<ref name="pmid194346582">{{cite journal| author=Pratt WB, Callery MP, Vollmer CM| title=The latent presentation of pancreatic fistulas. | journal=Br J Surg | year= 2009 | volume= 96 | issue= 6 | pages= 641-9 | pmid=19434658 | doi=10.1002/bjs.6614 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19434658  }}</ref>
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse may present in some patients.
*[[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 [[Pancreatic fistula|pancreatic fistulas]] is usually normal.
 
OR
 
*[[Cyanosis]]
*[[Jaundice]]
*[[Pallor]]
*Bruises
 
<gallery widths="150px">
File:UploadedImage-01.jpg| Description {{dermref}}
File:UploadedImage-02.jpg| Description {{dermref}}
</gallery>


===HEENT===
===HEENT===


*HEENT examination of patients with [disease name] is usually normal.
*HEENT examination of patients with [[Pancreatic fistula|pancreatic fistulas]] 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 accommodation / non-reactive to neither light nor accommodation
*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 [[Pancreatic fistula|pancreatic fistulas]] 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 [[Pancreatic fistula|pancreatic fistulas]] may shows the following due to large [[Pleural effusion|pleural effusions]]:<ref name="pmid10096323">{{cite journal| author=Fulcher AS, Capps GW, Turner MA| title=Thoracopancreatic fistula: clinical and imaging findings. | journal=J Comput Assist Tomogr | year= 1999 | volume= 23 | issue= 2 | pages= 181-7 | pmid=10096323 | doi=10.1097/00004728-199903000-00004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10096323  }}</ref>
 
**[[Dyspnea]]
OR
**[[Cough]]
 
**[[Wheeze|Wheezing]]
*Asymmetric chest expansion OR decreased chest expansion
**[[Pleuritic chest pain]]
*Lungs are hyporesonant OR hyperresonant
**Reduced breath sounds
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
**Dullness to [[percussion]]
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR 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 [[Pancreatic fistula|pancreatic fistulas]] 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 stethoscope


===Abdomen===
===Abdomen===


*Abdominal examination of patients with [disease name] is usually normal.
*Abdominal examination of patients with [[Pancreatic fistula|pancreatic fistulas]] is usually shows the following:


OR
*[[Abdominal distension]] due to fluid accumulation which can lead to [[ascites]].
*The [[ascites]] have the following physical examination findings:<ref name="pmid24650171">{{cite journal| author=Larsen M, Kozarek R| title=Management of pancreatic ductal leaks and fistulae. | journal=J Gastroenterol Hepatol | year= 2014 | volume= 29 | issue= 7 | pages= 1360-70 | pmid=24650171 | doi=10.1111/jgh.12574 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24650171  }}</ref><ref name="pmid19434658">{{cite journal| author=Pratt WB, Callery MP, Vollmer CM| title=The latent presentation of pancreatic fistulas. | journal=Br J Surg | year= 2009 | volume= 96 | issue= 6 | pages= 641-9 | pmid=19434658 | doi=10.1002/bjs.6614 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19434658  }}</ref>
**Fluid wave
**[[Shifting dullness]]
**Dullness to [[percussion]] at the flanks
**Weight loss
**[[Anorexia]]
**Weakness and severe malnutrition


*[[Abdominal distension]]
*Vague abdominal pain
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*Altered bowel habits which include:
*[[Rebound tenderness]] (positive Blumberg sign)
**[[Hematemesis]]
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
**[[Melena]] or [[hematochezia]]
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===


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


===Genitourinary===
===Genitourinary===


*Genitourinary examination of patients with [disease name] is usually normal.
*[[Genitourinary]] examination of patients with [[Pancreatic fistula|pancreatic fistulas]] is usually normal.
 
OR
 
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===


*Neuromuscular examination of patients with [disease name] is usually normal.
*[[Neuromuscular]] examination of patients with [[Pancreatic fistula|pancreatic fistulas]] 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===


*Extremities examination of patients with [disease name] is usually normal.
*Extremities examination of patients with [[Pancreatic fistula|pancreatic fistulas]] is usually normal.
 
OR
 
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==

Latest revision as of 15:10, 6 April 2021

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

Overview

Patients with pancreatic fistulas usually appear normal and in some they appear malnourished. Physical examination of patients with pancreatic fistulas is usually remarkable for infection, dyspnea, pleuritic chest pain and ascites.

Physical Examination

Physical examination of patients with internal pancreatic fistulas is usually normal or asymptomatic, on the other hand patients with external pancreatic fistulas can present with drainage of fluid.

Appearance of the Patient

Vital Signs

Skin

HEENT

Neck

Lungs

Heart

Abdomen

Back

Genitourinary

Neuromuscular

Extremities

References

  1. ↑ Pratt WB, Callery MP, Vollmer CM (2009). "The latent presentation of pancreatic fistulas". Br J Surg. 96 (6): 641–9. doi:10.1002/bjs.6614. PMID 19434658.
  2. ↑ Fulcher AS, Capps GW, Turner MA (1999). "Thoracopancreatic fistula: clinical and imaging findings". J Comput Assist Tomogr. 23 (2): 181–7. doi:10.1097/00004728-199903000-00004. PMID 10096323.
  3. ↑ Larsen M, Kozarek R (2014). "Management of pancreatic ductal leaks and fistulae". J Gastroenterol Hepatol. 29 (7): 1360–70. doi:10.1111/jgh.12574. PMID 24650171.
  4. ↑ Pratt WB, Callery MP, Vollmer CM (2009). "The latent presentation of pancreatic fistulas". Br J Surg. 96 (6): 641–9. doi:10.1002/bjs.6614. PMID 19434658.

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