Anal fistula physical examination: Difference between revisions

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{{Anal fistula}}
{{Anal fistula}}
{{CMG}} {{AE}} {{MKK}}
{{CMG}}, {{AE}}{{MKK}}
 
==Overview==
 
==Physical examination==
''Diagnosis'' is by examination, either in an [[outpatient]] setting or under [[anaesthesia]] (referred to as EUA - Examination Under Anaesthesia). The examination can be an [[anoscopy]].
 
Possible findings:
==Overview==
==Overview==
Patients with anal fistula usually appear in distress due to rectal pain. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with anal fistula usually appear in [[distress]] due to throbbing [[rectal pain]]. Patient presents with anal fistula is having normal vital signs but if [[anal fistula]] gets [[infected]], it will lead to the formation of an [[abscess]]. Patient with an [[abscess]] presents with unstable vitals like high-grade [[fever]], [[Tachycardia]], [[Tachypnea]], low [[Blood pressure|blood pressure]]. On rectal examination, there is redness, tenderness and discharge is seen.
 
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 of patients with [disease name] is usually normal.
OR
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*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 anal fistula usually appear in distress due to throbbing rectal pain.
*Patients with anal fistula usually appear in [[distress]] due to throbbing [[rectal pain]].
 
===Vital Signs===
===Vital Signs===
Patient presents with anal fistula is having normal vital signs but if anal fistula gets infected, it will lead to the formation of an abscess. Patient with an abscess presents with abnormal vitals:
Patient presents with anal fistula is having normal vital signs but if [[anal fistula]] gets [[infected]], it will lead to the formation of an [[abscess]]. Patient with an [[abscess]] presents with unstable vitals:
*High-grade fever
*High-grade [[fever]]
*[[Tachycardia]] with regular pulse  
*[[Tachycardia]] with regular [[pulse]]
*Tachypnea
*[[Tachypnea]]
*Low blood pressure with normal pulse pressure
*Low [[Blood pressure|blood pressure]]<nowiki/>e with normal [[pulse pressure]]
 
==Rectal Exam==
===Skin===
*Patient with [[anal fistula]] usually have throbbing [[rectal pain]]. The examination is usually done under [[sedation]].<ref name="urlwww.fascrs.org">{{cite web |url=https://www.fascrs.org/sites/default/files/downloads/publication/clinical_practice_guideline_for_the_management_of_anorectal_abscess_fistula-in-ano_and_rectovaginal_fistula.pdf |title=www.fascrs.org |format= |work= |accessdate=}}</ref><ref name="pmid27824697">{{cite journal |vauthors=Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL, Steele SR |title=Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula |journal=Dis. Colon Rectum |volume=59 |issue=12 |pages=1117–1133 |year=2016 |pmid=27824697 |doi=10.1097/DCR.0000000000000733 |url=}}</ref>
* Skin examination of patients with [disease name] is usually normal.
*On [[Inspection (medicine)|inspection]] perianal skin is [[red]] and excoriated.
OR
*On [[palpation]], there is [[tenderness]] and fluctuation due to [[abscess]].
*[[Cyanosis]]  
**The external opening can be palpated if it is just beneath the [[skin]].
*[[Jaundice]]
**The external opening is felt like a [[cord]] and [[discharge]] is seen.
* [[Pallor]]
*Bidigital [[rectal]] examination is usually done under the local [[anesthesia]] due to severe [[pain]].
* Bruises
 
<gallery widths="150px">
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>
 
===HEENT===
* HEENT examination of patients with [disease name] 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 examination of patients with [disease name] 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===
* Pulmonary examination of patients with [disease name] 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===
* Cardiovascular examination of patients with [disease name] 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===
Abdominal examination of patients with [disease name] is usually normal.
 
OR
*[[Abdominal distention]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
* Back examination of patients with [disease name] is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
* 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 examination of patients with [disease name] 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===
==Lymph Node Examnination==
* Extremities examination of patients with [disease name] is usually normal.
On palpation, [[Inguinal lymph node|inguinal lymph nodes]] are usually enlarged.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
*The opening of the fistula onto the skin may be seen
*The area may be painful on examination
*There may be redness
*An area of [[induration]] may be felt - thickening due to chronic infection
*A discharge may be seen
*It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula


==References==
==References==

Latest revision as of 20:29, 13 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

Patients with anal fistula usually appear in distress due to throbbing rectal pain. Patient presents with anal fistula is having normal vital signs but if anal fistula gets infected, it will lead to the formation of an abscess. Patient with an abscess presents with unstable vitals like high-grade fever, Tachycardia, Tachypnea, low blood pressure. On rectal examination, there is redness, tenderness and discharge is seen.

Appearance of the Patient

Vital Signs

Patient presents with anal fistula is having normal vital signs but if anal fistula gets infected, it will lead to the formation of an abscess. Patient with an abscess presents with unstable vitals:

Rectal Exam

Lymph Node Examnination

On palpation, inguinal lymph nodes are usually enlarged.

References

  1. ↑ "www.fascrs.org" (PDF).
  2. ↑ Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL, Steele SR (2016). "Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula". Dis. Colon Rectum. 59 (12): 1117–1133. doi:10.1097/DCR.0000000000000733. PMID 27824697.

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