Pancreatic cancer 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 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.  
 
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 palpable intra abdominal mass.
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), 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 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 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. 


===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
*afebrile
*[[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]]  
*[[Jaundice]]: Yellowish discoloration of skin, sclera
*[[Jaundice]]
**Associated with palpable, non-tender and distended gallbladder at the right costal margin (Courvoisier's sign) 
* [[Pallor]]
**Excoriations of the skin from unrelenting pruritus 
* Bruises
**Darkening of the urine 
** Acholic stools 
* [[Pallor]] ±
* Skin manifestations may include:
** Bullous pemphigoid
** Cicatricial pemphigoid
** Migratory superficial thrombophlebitis (classic Trousseau's syndrome)
** Pancreatic panniculitis:
*** Associated with acinar cell variant of pancreatic cancer
*** Located mostly on the legs
*** Appears as an erythematous subcutaneous area of nodular fat necrosis


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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]]
*Signs of metastatic disease include:
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
**Left supraclavicular lymphadenopathy (Virchow's node)  
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
**Palpable periumbilical mass (Sister Mary Joseph's node)  
*[[Thyromegaly]] / thyroid nodules
**Metastatic palpable mass in the rectal pouch (Blumer's shelf)
*[[Hepatojugular reflux]]
**Involvement of other 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 distention]]  
*[[Abdominal distention]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Abdominal tenderness]]:
*[[Rebound tenderness]] (positive Blumberg sign)
**Site: tenderness in 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 retroperitoneal 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 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, 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==

Revision as of 18:27, 15 November 2017

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

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

  • Physical examination of patients with pancreatic cancer is usually remarkable for: epigastric tenderness, jaundice, and palpable intra abdominal mass.
  • The presence of left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) on physical examination is diagnostic of metastasis.
  • The presence of ascites and a palpable, non tender gall bladder on physical examination is a common finding in pancreatic cancer patients.

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, 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.

Vital Signs

  • regular pulse
  • normal blood pressure
  • afebrile

Skin

  • Jaundice: Yellowish discoloration of skin, sclera
    • Associated with palpable, non-tender and distended gallbladder at the right costal margin (Courvoisier's sign)
    • Excoriations of the skin from unrelenting pruritus
    • Darkening of the urine
    •  Acholic stools
  • Pallor ±
  • Skin manifestations may include:
    • Bullous pemphigoid
    • Cicatricial pemphigoid
    • Migratory superficial thrombophlebitis (classic Trousseau's syndrome)
    • Pancreatic panniculitis:
      • Associated with acinar cell variant of pancreatic cancer
      • Located mostly on the legs
      • Appears as an erythematous subcutaneous area of nodular fat necrosis

Neck

  • Signs of metastatic disease 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)
    • Involvement of other nodes in the cervical area

Abdomen

  • Abdominal distention
  • Abdominal tenderness:
    • Site: tenderness in mid epigastric region
    • Onset: insidious
    • Character: gnawing, visceral quality
    • Radiation- mid/lower back due to tumor invasion of the retroperitoneal splanchnic nerve plexus
    • Relieving factors: relieved on lying down in a curled or fetal position may improve the pain
    • Aggravating factors: worse on lying supine or eating
    • Timing: intermittent
    • Severity- mild-moderate, worse at night
  • An abdominal mass may be palpable in the epigastrium.
  • Hepatomegaly may arise from liver metastasis
  • splenomegaly may arise from portal vein obstruction
  • hepatosplenomegaly
  • Fluid thrill and dullness to percussion may be present due to ascites

Genitourinary

  • In advanced stages of pancreatic cancer, metastatic palpable mass may be present in the rectal pouch.(Blumer's shelf)

References

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