Acute cholecystitis physical examination: Difference between revisions

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{{Acute cholecystitis}}
{{Acute cholecystitis}}


{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{SH}}


==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 acute cholecystitis usually appear ill. Physical examination of patients with acute cholecystitis is remarkable for [[Right upper quadrant pain|right upper quadrant abdominal tenderness]], positive [[murphy's sign]], and [[fever]]. The presence of [[murphy's sign]] on physical examination is highly suggestive of acute cholecystitis.


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==
 
{| align="right"
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
|[[File:Cholangitis Jaundice.jpg|thumb|250px|Sclerotic jaundice in a female patient with ascending cholangitis, Maracay, Venezuela.<ref>By Bobjgalindo - Own work, GFDL, https://commons.wikimedia.org/w/index.php?curid=10762793</ref>]]
*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].
*The presence of positive murphy's sign on physical examination is highly suggestive of acute cholecysitis.<ref name="pmid8632396">{{cite journal |vauthors=Adedeji OA, McAdam WA |title=Murphy's sign, acute cholecystitis and elderly people |journal=J R Coll Surg Edinb |volume=41 |issue=2 |pages=88–9 |year=1996 |pmid=8632396 |doi= |url=}}</ref><ref name="pmid1486206">{{cite journal |vauthors=Diehl AK |title=Symptoms of gallstone disease |journal=Baillieres Clin. Gastroenterol. |volume=6 |issue=4 |pages=635–57 |year=1992 |pmid=1486206 |doi= |url=}}</ref><ref name="pmid18579815">{{cite journal |vauthors=Strasberg SM |title=Clinical practice. Acute calculous cholecystitis |journal=N. Engl. J. Med. |volume=358 |issue=26 |pages=2804–11 |year=2008 |pmid=18579815 |doi=10.1056/NEJMcp0800929 |url=}}</ref><ref name="pmid8780468">{{cite journal |vauthors=Singer AJ, McCracken G, Henry MC, Thode HC, Cabahug CJ |title=Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis |journal=Ann Emerg Med |volume=28 |issue=3 |pages=267–72 |year=1996 |pmid=8780468 |doi= |url=}}</ref><ref name="pmid9095024">{{cite journal |vauthors=Cooper C |title=Acute cholecystitis |journal=Ann Emerg Med |volume=29 |issue=4 |pages=554–5 |year=1997 |pmid=9095024 |doi= |url=}}</ref><ref name="pmid19190960">{{cite journal |vauthors=Fitzgerald JE, White MJ, Lobo DN |title=Courvoisier's gallbladder: law or sign? |journal=World J Surg |volume=33 |issue=4 |pages=886–91 |year=2009 |pmid=19190960 |doi=10.1007/s00268-008-9908-y |url=}}</ref><ref name="pmid26615166">{{cite journal |vauthors=Katabathina VS, Zafar AM, Suri R |title=Clinical Presentation, Imaging, and Management of Acute Cholecystitis |journal=Tech Vasc Interv Radiol |volume=18 |issue=4 |pages=256–65 |year=2015 |pmid=26615166 |doi=10.1053/j.tvir.2015.07.009 |url=}}</ref><ref name="pmid27862628">{{cite journal |vauthors=Jain A, Mehta N, Secko M, Schechter J, Papanagnou D, Pandya S, Sinert R |title=History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis |journal=Acad Emerg Med |volume=24 |issue=3 |pages=281–297 |year=2017 |pmid=27862628 |doi=10.1111/acem.13132 |url=}}</ref>


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].
*Ill appearing
*In severe distress


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


*High-grade / low-grade fever
*High-grade fever  
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Tachypnea]]
*[[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]]
*[[Jaundice]]
* [[Pallor]]
* Bruises
<gallery widths=150px>
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
</gallery>
===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===
*[[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===
* 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]]
*Right upper quadrant [[abdominal tenderness]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]]
*[[Rebound tenderness]] (positive Blumberg sign)
*Palpable gallbladder, positive [[Courvoisier's sign]]<ref name="pmid19864733">{{cite journal |vauthors=Munzer D |title=Assessment of Courvoisier's law |journal=Saudi J Gastroenterol |volume=5 |issue=3 |pages=106–12 |year=1999 |pmid=19864733 |doi= |url=}}</ref>
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Voluntary and involuntary guarding may be present
*Guarding may be present
*[[Murphy's sign|Murphy's]] test positive
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
*Patient is usually well oriented
* Altered mental status
*Altered mental status can be observed in some patients
* 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==

Latest revision as of 21:13, 20 February 2018

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

Overview

Patients with acute cholecystitis usually appear ill. Physical examination of patients with acute cholecystitis is remarkable for right upper quadrant abdominal tenderness, positive murphy's sign, and fever. The presence of murphy's sign on physical examination is highly suggestive of acute cholecystitis.

Physical Examination

Sclerotic jaundice in a female patient with ascending cholangitis, Maracay, Venezuela.[1]
  • The presence of positive murphy's sign on physical examination is highly suggestive of acute cholecysitis.[2][3][4][5][6][7][8][9]

Appearance of the Patient

  • Ill appearing
  • In severe distress

Vital Signs

Skin

Abdomen

Neuromuscular

  • Patient is usually well oriented
  • Altered mental status can be observed in some patients

References

  1. ↑ By Bobjgalindo - Own work, GFDL, https://commons.wikimedia.org/w/index.php?curid=10762793
  2. ↑ Adedeji OA, McAdam WA (1996). "Murphy's sign, acute cholecystitis and elderly people". J R Coll Surg Edinb. 41 (2): 88–9. PMID 8632396.
  3. ↑ Diehl AK (1992). "Symptoms of gallstone disease". Baillieres Clin. Gastroenterol. 6 (4): 635–57. PMID 1486206.
  4. ↑ Strasberg SM (2008). "Clinical practice. Acute calculous cholecystitis". N. Engl. J. Med. 358 (26): 2804–11. doi:10.1056/NEJMcp0800929. PMID 18579815.
  5. ↑ Singer AJ, McCracken G, Henry MC, Thode HC, Cabahug CJ (1996). "Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis". Ann Emerg Med. 28 (3): 267–72. PMID 8780468.
  6. ↑ Cooper C (1997). "Acute cholecystitis". Ann Emerg Med. 29 (4): 554–5. PMID 9095024.
  7. ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
  8. ↑ Katabathina VS, Zafar AM, Suri R (2015). "Clinical Presentation, Imaging, and Management of Acute Cholecystitis". Tech Vasc Interv Radiol. 18 (4): 256–65. doi:10.1053/j.tvir.2015.07.009. PMID 26615166.
  9. ↑ Jain A, Mehta N, Secko M, Schechter J, Papanagnou D, Pandya S, Sinert R (2017). "History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis". Acad Emerg Med. 24 (3): 281–297. doi:10.1111/acem.13132. PMID 27862628.
  10. ↑ Munzer D (1999). "Assessment of Courvoisier's law". Saudi J Gastroenterol. 5 (3): 106–12. PMID 19864733.

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