Acute diarrhea physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]
Overview
Patients with Acute diarrhea usually appear ill, dehydrated or lethargic. Common physical examination findings of Acute diarrhea include hypotension and other signs of volume depletion(depressed consciousness, sunken anterior fontanel, dry mucous membranes, poor skin turgor and delayed capillary refill), abdominal tenderness and distension, increased peristalytic activity(borborygmi).
Physical Examination
- Physical examination of patients with Acute diarrhea shows signs of dehydration( dry mouth and tongue, sunken eyes, sunken anterior fontanel, Poor skin turgor, hypotension,altered consciousness,absent tears), abdominal tenderness and distension, increased peristalytic activity,perineal erythema and signs of malnutrition.
Appearance of the Patient
- Patients with acute diarrhea may appear ill, dehydrated, or lethargic depending upon the severity of diarrhea.
Vital Signs
- Hypotension
- Fever
- Orthostasis
- Tachycardia or bradycardia
Assessment of dehydration:[1]
- Dehydration is the major cause of morbidity and mortality in diarrhea.
- Every patient with diarrhea should be assessed for signs, symptoms, and severity.
- Common findings of volume depletion on physical exam include Lethargy, depressed consciousness, diminshed skin turgor, sunken anterior fontanel, dry mucous membranes, sunken eyes, lack of tears, and delayed capillary refill are obvious and important signs of dehydration.
| Mild dehydration (<5%) | Moderate dehydration (5-10%) | Severe dehydration | |
|---|---|---|---|
| Eyes | Normal | Sunken | Very sunken |
| Tears | Present | Absent | Absent |
| Thirst | Normal | Thirsty | Poor |
| Mouth | Moist | Dry | Very dry |
| Urine output | Normal | Decreased | Oliguric |
| Fontanelle | Normal | Sunken | Sunken |
| Respirations | Normal | Tachypnea | Tachypnea |
| Mental status | Normal | Irritable | Altered |
| Blood pressure | Normal | Hypotension | Hypotension |
Skin
- Skin examination of patients with diarrhea can be done by pinch test.
- If the skin on the thigh, calf, or forearm is pinched , it will immediately return to its normally flat state when the pinch is released in normal patients.
- Mild dehydration(0-5%): Pinch retracts immediately
- Moderate dehydration(5-10%): Pinch retracts slowly
- Severe dehydration(>10%): Pinch remain folded
- Delayed capillary refill
Heart
- Hypotension
- Tachycardia/ Bradycardia
- Decreased jugular venous pressure
Abdomen
- Abdominal distention
- Diffuse Abdominal tenderness
- Borborygmi
- Rigidity and rebound abdominal tenderness
- Hepatospleenomegaly is associated with certain infections (eg: Mycobacterium Avium complex, Salmonellosis)
Perineal erythema
- In children mostly, frequent passage of stools cause perineal skin breakdown.
- Carbohydrate malabsorption seconadary to diarrhea may be responsible for more acidic stools that results in erythema.
- Bile acid malabsorption leads to diaper dermatitis that is severe, appears as burnt perianal skin.
Failure to thrive and malnutrition
- Reductions in muscle and fat mass or peripheral edema may be present in presence of underlying carbohydrate, fat, and/or protein malabsorption.
- Giardia organisms can cause intermittent diarrhea and fat malabsorption.
Lungs
- Examination is usually normal.
- Tachypnea caused by metabolic acidosis as aresult of severe volume depletion.
HEENT
- Sunken anterior fontanelle
- Oral mucosal lesions and angular stomatitis in Tropical sprue.
- Dry mucous membranes and tongue.
Neuromuscular
- Irritability or lethargy
- Muscle weakness and convulsions because of moderate to severe electrolyte imbalance.