Appendix cancer physical examination: Difference between revisions

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{{Appendix cancer}}
{{Appendix cancer}}


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{Soroush}}


==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 [[Vermiform appendix|appendix]] [[cancer]] usually appear normal, [[Pallor|pale]] or [[Diaphoresis|diaphoretic]]. If the patient with appendix cancer present with [[acute appendicitis]] which is quite common, [[abdominal tenderness]], [[rebound tenderness]], [[Abdominal guarding|abdominal guarding,]] [[Rovsing's sign|Rovsing's sign,]] as well as [[Psoas sign]] might be present. Around 5% of the patients with appendiceal [[Carcinoid Tumor|carcinoid tumors]] might develop [[carcinoid syndrome]]. Common physical examination findings of [[carcinoid syndrome]] include [[dehydration]] due to [[diarrhea]], [[tachycardia]] as well as [[Flushing|facial flushing]], [[Heart murmurs|right heart murmurs]] like [[Tricuspid regurgitation|TR murmur]] is quit common. In patients with [[carcinoid syndrome]], the presence of [[dermatitis]], [[diarrhea]], and [[dementia]] on [[physical examination]] is highly suggestive of [[Pellagra]] disease.
 
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 normal.


OR
*[[Physical examination]] of patients with [[appendix cancer]] is usually normal.<ref name="WHO">Chapter 5: Tumours of the Appendix - IARC. https://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb2/bb2-chap5.pdf Accessed on January 15, 2019</ref>
 
*If the patient with appendix cancer present with [[acute appendicitis]] which is quite common, [[abdominal tenderness]], [[rebound tenderness]], [[Abdominal guarding|abdominal guarding,]] [[Rovsing's sign|Rovsing's sign,]] as well as [[Psoas sign]] might be present. <ref>Hardin, M. Acute Appendicitis: Review and Update. ''Am Fam Physician".1999, Nov 1;60(7):2027-2034''</ref>
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
*Around 5% of the patients with appendiceal [[Carcinoid Tumor|carcinoid]] tumors might develop [[carcinoid syndrome]].
 
*Common physical examination findings of [[carcinoid syndrome]] include dehydration due to [[diarrhea]], [[tachycardia]] as well as facial [[flushing]], [[Heart murmur|right heart murmurs]] like [[Tricuspid regurgitation|TR]] [[Heart murmur|murmur]] is quit common.<ref name="ss">Signs and symptoms of carcinoid syndrome. National Cancer Institute. http://www.cancer.gov/types/gi-carcinoid-tumors/patient/gi-carcinoid-treatment-pdq</ref>
OR
*In patients with [[carcinoid syndrome]], the presence of [[dermatitis]], [[diarrhea]], and [[dementia]] on physical examination is highly suggestive of [[Pellagra]] disease.<ref name="pmid14693013">Hegyi J, Schwartz RA, Hegyi V (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14693013 Pellagra: dermatitis, dementia, and diarrhea.] ''Int J Dermatol'' 43 (1):1-5. PMID: [https://pubmed.gov/14693013 14693013]</ref>
 
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 [disease name] usually appear [general appearance].  
*Patients with appendix cancer usually appear normal but might be pale or [[Diaphoresis|diaphoretic]], or even present with a facial [[flushing]].  


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


*High-grade / low-grade fever
*[[Fever]] might be present in patients presenting with appendicitis.
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] is prevalent in patients with [[carcinoid syndrome]] as well as patients with [[appendicitis]].
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Tachypnea]]
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Hypertension]]
*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 appendix cancer is usually normal.
OR
* In the presence of [[carcinoid syndrome]] the following might be present:
*[[Cyanosis]]  
**[[Flushing]]  
*[[Jaundice]]
** [[Hirsutism]]
* [[Pallor]]
** [[Pallor]]
* Bruises
** [[Dermatitis]] in the presence of [[Pellagra]]
 
<gallery widths="150px">
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* HEENT examination of patients with appendix cancer is usually normal.
OR
* [[Glossitis]] may be suggestive of [[Pellagra]].
* 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 appendiceal cancer is usually normal.
OR
* [[Lymphadenopathy|Cervical lymphadenopathy]] might be present.
*[[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.
* [[Lung|Pulmonary]] examination of patients with [[appendix cancer]] is usually normal.
OR
* [[Wheezing]] : If the patient develop [[carcinoid syndrome]].
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*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.
* [[Circulatory system|Cardiovascular]] examination of patients with appendix cancer is usually normal.
OR
* If the patient develop [[carcinoid syndrome]] [[Murmur|systolic or diastolic murmur]] might be present.
*Chest tenderness upon palpation
* Right [[Heart murmur|heart murmurs]] specially [[Tricuspid regurgitation|TR]] is prevalent.
*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.
* Considering small size of must of appendiceal [[Tumor|tumors]], abdominal examination of patients with appendix cancer is usually normal.
OR
* But in the cases of complicated tumors such as perforated [[appendicitis]], [[abdominal examination]] may be remarkable for:
*[[Abdominal distension]]  
**[[Abdominal tenderness]] in the right lower abdominal quadrant  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant  
**[[Rebound tenderness]]  
*[[Rebound tenderness]] (positive Blumberg sign)
**A palpable [[abdominal mass]] in the right lower abdominal quadrant
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
**[[Abdominal guarding|Guarding]] may be present
*Guarding may be present
*In cases of late stage [[metastatic]] disease [[hepatosplenomegaly]] might be present.
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as [[obturator]] test, [[Psoas sign|Psoas]] test, McBurney point test are common in [[Appendicitis diagnostic scoring|appendicitis]].
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
'''''Palpation'''''
* The abdominal wall is very sensitive to mild palpation:
** [[Rebound tenderness]]
** [[Abdominal guarding]]
** [[Rovsing's sign]]
** [[Psoas sign]]
'''''Rectal examination'''''
* [[Tenderness]] in the [[rectovesical pouch]]


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


===Genitourinary===
*A pelvic [[Adnexal mass causes|adnexal mass]] may be palpated; in fact a number of appendiceal cancers are misdiagnosed as [[Ovarian cancer|ovarian masses]] vise versa.
* Genitourinary examination of patients with [disease name] 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 appendix cancer is usually normal.  
OR
* [[Dementia]], aggression, and [[mental confusion]] are rare complications of complicated [[carcinoid syndrome]] patients that develop [[Pellagra]].
*Patient is usually oriented to persons, place, and time
===Extremities===
* Altered mental status
* [[Limb (anatomy)|Extremities]] examination of patients with appendix cancer is usually normal.
* 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===
*Rarely patients with [[Carcinoid syndrome|carcinoid]] syndrome might present with [[Edema|lower limb edema]].
* Extremities examination of patients with [disease name] 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==
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[[Category: (name of the system)]]
[[Category:Surgery]]
[[Category:Medicine]]
[[Category:Emergency medicine]]
[[Category:Oncology]]
[[Category:Up-To-Date]]

Latest revision as of 17:49, 22 February 2019

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

Overview

Patients with appendix cancer usually appear normal, pale or diaphoretic. If the patient with appendix cancer present with acute appendicitis which is quite common, abdominal tenderness, rebound tenderness, abdominal guarding, Rovsing's sign, as well as Psoas sign might be present. Around 5% of the patients with appendiceal carcinoid tumors might develop carcinoid syndrome. Common physical examination findings of carcinoid syndrome include dehydration due to diarrhea, tachycardia as well as facial flushing, right heart murmurs like TR murmur is quit common. In patients with carcinoid syndrome, the presence of dermatitis, diarrhea, and dementia on physical examination is highly suggestive of Pellagra disease.

Physical Examination

Appearance of the Patient

  • Patients with appendix cancer usually appear normal but might be pale or diaphoretic, or even present with a facial flushing.

Vital Signs

Skin

HEENT

  • HEENT examination of patients with appendix cancer is usually normal.
  • Glossitis may be suggestive of Pellagra.

Neck

Lungs

Heart

Abdomen

Palpation

Rectal examination

Back

  • Back examination of patients with appendix cancer is usually normal.

Genitourinary

  • Genitourinary examination of patients with appendix cancer is usually normal.

Neuromuscular

Extremities

  • Extremities examination of patients with appendix cancer is usually normal.

References

  1. ↑ Chapter 5: Tumours of the Appendix - IARC. https://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb2/bb2-chap5.pdf Accessed on January 15, 2019
  2. ↑ Hardin, M. Acute Appendicitis: Review and Update. Am Fam Physician".1999, Nov 1;60(7):2027-2034
  3. ↑ Signs and symptoms of carcinoid syndrome. National Cancer Institute. http://www.cancer.gov/types/gi-carcinoid-tumors/patient/gi-carcinoid-treatment-pdq
  4. ↑ Hegyi J, Schwartz RA, Hegyi V (2004) Pellagra: dermatitis, dementia, and diarrhea. Int J Dermatol 43 (1):1-5. PMID: 14693013

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