Systemic lupus erythematosus physical examination: Difference between revisions

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{{Systemic lupus erythematosus}}
{{Systemic lupus erythematosus}}


{{CMG}}; {{AE}} {{RT}} {{KS}}
{{CMG}}; {{AE}} {{MIR}}


==Overview==
==Overview==
In the earlier stages of the disease, patients appear well, while in the late stages of the disease, patients are clearly ill with multi-organ involvement. The patient may show a wide range of skin manifestations including [[urticaria]], [[Bullous|bullous lesions]], [[malar rash]], and scarring [[alopecia]]. The patient may develop nasal and [[oral ulcers]]. [[Arthritis]] may lead to a decreased [[range of motion]], joint effusion, and [[arthralgia]]. Neurological manifestations including [[psychosis]], [[cognitive impairment]], and [[hallucinations]], may also be present. 


==Physical Examination==
==Physical Examination==
===Appearance of the Patient===
===Appearance of the Patient===
*This section should give a general description of what a patient with the disease you are describing may look like.
*Patient appears well in the earlier stages of the disease
*If patients typically appear normal, you may write: Patients are usually well-appearing.
*Patient appears ill in the late stages of the disease due to multi-organ involvement
*You may include a physical description such as obese, thin, cachectic, ill appearing, diaphoretic etc. Mention in which cases these findings are present (e.g. well-appearing in early stages of cancer, cachectic in late stage cancer)
*For an example of the appearance of a patient section in the physical examination page, click [[Stomach cancer physical examination|here]].
===Vital Signs===
===Vital Signs===
<sup>Note: Vital signs traditionally include the temperature, blood pressure, heart rate, respiratory rate. The vital signs may also include oxygen saturation (at room air) and blood glycemia.</sup>
*[[Fever]] higher than 38 after the exclusion of [[infection]]
*High-grade / low-grade fever
*[[Tachycardia]]/[[bradycardia]] depends on the accompanying complication
*[[Hypothermia]] / hyperthermia may be present
*[[Tachypnea]]/[[bradypnea]] depends on the accompanying complication
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
 
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
=== Skin<ref name="pmid25077888">{{cite journal |vauthors=Parodi A, Cozzani E |title=Cutaneous manifestations of lupus erythematosus |journal=G Ital Dermatol Venereol |volume=149 |issue=5 |pages=549–54 |year=2014 |pmid=25077888 |doi= |url=}}</ref><ref name="pmid26985173">{{cite journal |vauthors=Szczęch J, Rutka M, Samotij D, Zalewska A, Reich A |title=Clinical characteristics of cutaneous lupus erythematosus |journal=Postepy Dermatol Alergol |volume=33 |issue=1 |pages=13–7 |year=2016 |pmid=26985173 |pmc=4793050 |doi=10.5114/pdia.2014.44031 |url=}}</ref><ref name="pmid19824738">{{cite journal |vauthors=Walling HW, Sontheimer RD |title=Cutaneous lupus erythematosus: issues in diagnosis and treatment |journal=Am J Clin Dermatol |volume=10 |issue=6 |pages=365–81 |year=2009 |pmid=19824738 |doi=10.2165/11310780-000000000-00000 |url=}}</ref> ===
*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===
*[[Cyanosis]]
*[[Cyanosis]]
**Secondary to [[respiratory]] complications
*[[Jaundice]]
*[[Jaundice]]
**Secondary to [[hepatitis]]
*[[Pallor]]
*[[Pallor]]
*Bruises
**Secondary to [[anemia]]
Note: To describe a rash, always report additional details that include the color (e.g. erythematous), shape (e.g. flat / bullous), dermarcation (e.g. well-circumscribed / diffuse), location (e.g. truncal / on the face / on the extremities), enclosing fluid (e.g. vesicular / filled with pus, clear), and if possible smell (e.g. foul-smelling / odorless)<gallery widths="150px">
*Generalised [[erythema]]
*[[Bruises]]
**Secondary to [[thrombocytopenia]]
*[[Urticaria]]
*[[Bullous|Bullous lesions]]
*[[Sclerodactyly]]
*Skin [[Ulcerations|ulceration]]
*[[Malar rash]]: the classic lupus ‘butterfly’ rash
** [[Erythema|Erythematous]], elevated [[Lesions|lesion]], [[Pruritis|pruritic]] or painful, in a [[malar]] distribution, commonly precipitated by exposure to sunlight
* Annular or psoriasiform skin [[lesions]]
** Small, [[erythematous]], slightly scaly [[papules]] that evolve into either a psoriasiform (papulosquamous) or annular form and tend to involve shoulders, forearms, neck, and upper torso
* [[Scarring]] [[chronic]] [[alopecia]]
** Mostly present on face, neck, and scalp
* [[Telangiectasias]]
* Dyspigmentation ([[hyperpigmentation]] or [[hypopigmentation]]) of skin in [[scar]] places
* Follicular plugging
** Discrete, [[erythematous]], slightly infiltrated [[plaques]] covered by a well-formed adherent scale that extends into dilated [[hair follicles]]
* [[Nodules]]
** Can be firm (Lupus profundus) and painful
* Photodistributed [[lesions]] with chronic pink indurated plaques or broad [[lesions]] that are slow to heal (more seen in lupus tumidus)
* Thin hair that easily fractures (lupus hair)
* Irregularly shaped raised white plaques, areas of erythema, silvery white scarred [[lesions]], and [[ulcers]] with surrounding [[erythema]] on the soft or hard palate or buccal [[mucosa]]
* Periungual [[erythema]]
** Dilated tortuous loops of [[capillaries]] and a prominent subcapillary venous plexus along
** Involves the base of the nail and edges of the upper [[eyelid]]
[[File:Systemic lupus erythematosus 055.jpg|300px]]
'''For more pictures of the rash presentation in lupus, click [[Systemic lupus eryhthematosus physical examination:Gallery|here]].'''


UploadedImage-01.jpg | Description {{dermref}}
===HEENT===
UploadedImage-02.jpg | Description {{dermref}}
*[[Ophthalmology]]<ref name="pmid26367085">{{cite journal |vauthors=Preble JM, Silpa-archa S, Foster CS |title=Ocular involvement in systemic lupus erythematosus |journal=Curr Opin Ophthalmol |volume=26 |issue=6 |pages=540–5 |year=2015 |pmid=26367085 |doi=10.1097/ICU.0000000000000209 |url=}}</ref><ref name="pmid25904124">{{cite journal |vauthors=Silpa-archa S, Lee JJ, Foster CS |title=Ocular manifestations in systemic lupus erythematosus |journal=Br J Ophthalmol |volume=100 |issue=1 |pages=135–41 |year=2016 |pmid=25904124 |doi=10.1136/bjophthalmol-2015-306629 |url=}}</ref>
**[[Nystagmus]]
**Visual [[Retinal|retinal changes]] from systemic lupus erythematosus cytoid bodies, [[Retina|retinal]] [[haemorrhages]], serous exudate or [[haemorrhage]] in the [[choroid]], [[optic neuritis]] (not due to [[hypertension]], drugs or [[infection]])
**[[Cataract]]
**[[Optic nerve atrophy]]
**[[Icterus|Icteric sclera]]
**[[Cotton wool spots]] in the [[retina]] in [[Ophthalmoscopy|ophthalmoscopic exam]]
*Nasal [[ulcers]]<ref name="pmid1526055">{{cite journal |vauthors=Robson AK, Burge SM, Millard PR |title=Nasal mucosal involvement in lupus erythematosus |journal=Clin Otolaryngol Allied Sci |volume=17 |issue=4 |pages=341–3 |year=1992 |pmid=1526055 |doi= |url=}}</ref>
**Mostly painless
**Mostly in lower [[nasal septum]] and [[bilateral]] and parallel
**Nasal perforation secondary to [[vasculitis]] may happen rarely
*Oral [[ulcers]]<ref name="pmid23780804">{{cite journal |vauthors=Anyanwu CO, Ang CC, Werth VP |title=Oral mucosal involvement in bullous lupus |journal=Arthritis Rheum. |volume=65 |issue=10 |pages=2622 |year=2013 |pmid=23780804 |pmc=4333153 |doi=10.1002/art.38051 |url=}}</ref><ref name="pmid23248469">{{cite journal |vauthors=Ranginwala AM, Chalishazar MM, Panja P, Buddhdev KP, Kale HM |title=Oral discoid lupus erythematosus: A study of twenty-one cases |journal=J Oral Maxillofac Pathol |volume=16 |issue=3 |pages=368–73 |year=2012 |pmid=23248469 |pmc=3519212 |doi=10.4103/0973-029X.102487 |url=}}</ref>
**Mostly painless
**White plaques with areas of [[erythema]], or punched-out erosions or ulcers with surrounding [[erythema]] on the soft or hard palate or [[buccal mucosa]]


</gallery>
===Neck<ref name="pmid19107085">{{cite journal |vauthors=Melikoglu MA, Melikoglu M |title=The clinical importance of lymphadenopathy in systemic lupus erythematosus |journal=Acta Reumatol Port |volume=33 |issue=4 |pages=402–6 |year=2008 |pmid=19107085 |doi= |url=}}</ref><ref name="pmid24722263">{{cite journal |vauthors=Sacre K, Escoubet B, Pasquet B, Chauveheid MP, Zennaro MC, Tubach F, Papo T |title=Increased arterial stiffness in systemic lupus erythematosus (SLE) patients at low risk for cardiovascular disease: a cross-sectional controlled study |journal=PLoS ONE |volume=9 |issue=4 |pages=e94511 |year=2014 |pmid=24722263 |pmc=3983200 |doi=10.1371/journal.pone.0094511 |url=}}</ref>===
===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]]
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
**Secondary to [[hypertension]] and cardiac complications
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Lymphadenopathy]]  
*[[Thyromegaly]] / thyroid nodules
** [[Lymph node|Lymph nodes]] are soft, non-tender, discrete
*[[Hepatojugular reflux]]
** Usually detected in the [[cervical]], [[axillary]], and [[inguinal]]
===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 S1.2C the .22lub.22.28components M1 and T1.29|S1]]
*[[Heart sounds#Second heart tone S2 the .22dub.22.28components A2 and P2.29|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 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===
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally (may also be referred to as Murphy's punch sign, which is different from Murphy's sign that suggests cholecystitis. To avoid confusion, write "costovertebral angle tenderness")
*Buffalo hump
===Genitourinary===
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
<sup>Write additional pathognomonic findings, such as discharge that resembles cottage cheese for ''C. albicans'' vulvovaginitis / fish-odor for ''T. vaginalis'' ifnection</sup>
===Extremities===
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
===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)
{| class="wikitable"
!
!
!
!
|-
|Constitutional symptoms
|Fatigue
|the most common complaint 11085805
multidimensional phenomenon due to different factors 7779127


does not correlate with disease activity 9598886
===Lungs<ref name="pmid21194884">{{cite journal |vauthors=Torre O, Harari S |title=Pleural and pulmonary involvement in systemic lupus erythematosus |journal=Presse Med |volume=40 |issue=1 Pt 2 |pages=e19–29 |year=2011 |pmid=21194884 |doi=10.1016/j.lpm.2010.11.004 |url=}}</ref><ref name="pmid26550810">{{cite journal |vauthors=Salvati F |title=[The involvement of pulmonary interstitial tissue in multisystemic lupus erythematosus: interdisciplinarity and role of the pneumologists] |language=Italian |journal=Clin Ter |volume=166 |issue=5 |pages=205–7 |year=2015 |pmid=26550810 |doi= |url=}}</ref><ref name="pmid25639532">{{cite journal |vauthors=Alamoudi OS, Attar SM |title=Pulmonary manifestations in systemic lupus erythematosus: association with disease activity |journal=Respirology |volume=20 |issue=3 |pages=474–80 |year=2015 |pmid=25639532 |pmc=4418345 |doi=10.1111/resp.12473 |url=}}</ref>===
|frequently associated with depression, sleep disturbances, and concomitant fibromyalgia
*Fine and coarse [[crackles]] upon auscultation of the [[lung]]
|-
**May be due to [[pneumonitis]]
|
*In case of [[pleural effusion]]:
|Fever
**Asymmetric [[tactile fremitus]]
|a manifestation of active disease-lupus flare, especially within short-term evolution of the disease 14530779
**Asymmetric [[chest expansion]]
Can be hard to differentiate the cause of fever from other inflammatory and infection diseases


Leukopenia or normal range of leukocytes in the setting of fever is more suggestive of lupus activity rather than infection
===Heart<ref name="pmid24790989">{{cite journal |vauthors=Mak A, Kow NY |title=Imbalance between endothelial damage and repair: a gateway to cardiovascular disease in systemic lupus erythematosus |journal=Biomed Res Int |volume=2014 |issue= |pages=178721 |year=2014 |pmid=24790989 |pmc=3984775 |doi=10.1155/2014/178721 |url=}}</ref><ref name="pmid24722263">{{cite journal |vauthors=Sacre K, Escoubet B, Pasquet B, Chauveheid MP, Zennaro MC, Tubach F, Papo T |title=Increased arterial stiffness in systemic lupus erythematosus (SLE) patients at low risk for cardiovascular disease: a cross-sectional controlled study |journal=PLoS ONE |volume=9 |issue=4 |pages=e94511 |year=2014 |pmid=24722263 |pmc=3983200 |doi=10.1371/journal.pone.0094511 |url=}}</ref><ref name="pmid23052654">{{cite journal |vauthors=Canpolat N, Kasapcopur O, Caliskan S, Gokalp S, Bor M, Tasdemir M, Sever L, Arisoy N |title=Ambulatory blood pressure and subclinical cardiovascular disease in patients with juvenile-onset systemic lupus erythematosus |journal=Pediatr. Nephrol. |volume=28 |issue=2 |pages=305–13 |year=2013 |pmid=23052654 |doi=10.1007/s00467-012-2317-3 |url=}}</ref>===
|
*Chest [[tenderness]] or discomfort upon palpation
|-
**May be due to [[costochondritis]]
|
*[[Diastolic murmurs|Diastolic murmur]], or [[Systolic murmurs|systolic murmur]] >3/6 due to [[valvular disease]]
|Myalgia
*Loud second heart sound (due to [[pulmonary hypertension]])
muscle tenderness
*Loud S1-S2 due to [[cardiomegaly]]
*Decrease heart sounds if associated with [[pericardial effusion]]


muscle weakness
===Abdomen<ref name="pmid20572299">{{cite journal |vauthors=Tian XP, Zhang X |title=Gastrointestinal involvement in systemic lupus erythematosus: insight into pathogenesis, diagnosis and treatment |journal=World J. Gastroenterol. |volume=16 |issue=24 |pages=2971–7 |year=2010 |pmid=20572299 |pmc=2890936 |doi= |url=}}</ref><ref name="pmid27329649">{{cite journal |vauthors=Alves SC, Fasano S, Isenberg DA |title=Autoimmune gastrointestinal complications in patients with systemic lupus erythematosus: case series and literature review |journal=Lupus |volume=25 |issue=14 |pages=1509–1519 |year=2016 |pmid=27329649 |doi=10.1177/0961203316655210 |url=}}</ref><ref name="pmid27055518">{{cite journal |vauthors=Fawzy M, Edrees A, Okasha H, El Ashmaui A, Ragab G |title=Gastrointestinal manifestations in systemic lupus erythematosus |journal=Lupus |volume=25 |issue=13 |pages=1456–1462 |year=2016 |pmid=27055518 |doi=10.1177/0961203316642308 |url=}}</ref><ref name="pmid28523968">{{cite journal |vauthors=Li Z, Xu D, Wang Z, Wang Y, Zhang S, Li M, Zeng X |title=Gastrointestinal system involvement in systemic lupus erythematosus |journal=Lupus |volume= |issue= |pages=961203317707825 |year=2017 |pmid=28523968 |doi=10.1177/0961203317707825 |url=}}</ref>===
|may be first complaint and initial reason for the patient to seeks medical attention
*[[Abdominal distention]]
May happen as a result of treatment with glucocorticoids or glucocorticoid withdrawal
*[[Ascites]]
|perivascular and perifascicular mononuclear cell infiltrates in 25 percent of patients
**Due to [[nephrotic syndrome]]
muscle atrophy, microtubular inclusions, mononuclear infiltrate, fiber necrosis, and, occasionally, vacuolated muscle fibers  2319520
*[[Abdominal pain]]
|-
**Due to [[Vasculitis|mesentric vasculitis]]
|
*[[Hepatomegaly]]
|Weight change
*[[Splenomegaly]]
|
*Costo-vertebral angle tenderness
* Weight loss due to:
** Decreased appetite
** Side effects of medications (particularly diuretics)
** Gastrointestinal symptoms related to lupus (e.g. gastroesophageal reflux, abdominal pain, peptic ulcer disease, or pancreatitis)
* Weight gain due to:
** Hypoalbuminemia:
*** Result in salt and water retention (e.g. due to nephrotic syndrome or protein losing enteropathy)
** Increased appetite associated with the use of glucocorticoids
|
|-
|Extremities
|Arthritis
|
* migratory arthritis means that the symptoms may be gone by 24 hours
* Usually symmetrical and polyarticular with a predilection for the knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint
* Morning stiffness with a really short duration (less than 1 hour)
* Painful arthritis and decrease range of motion
* The SLE arthritis is mostly nondeforming
* It has been noted that 15-50% of patients may develop flexion deformities, ulnar deviation, soft tissue laxity, and swan neck deformities 3041493  9849313 19591780 7841997
12528115
* Synovial effusions are infrequent in patients with SLE, usually small with slightly cloudy or clear fluid
* septic arthritis may occurs as a result of low immune response and medication. it can be secondary to infections with Salmonella, gonococci, meningococci, and other organisms
|
|-
|Skin and mucous membrane involvement 
|acute cutaneous lupus erythema (ACLE) (also known as “the butterfly rash”)
|
* Localized ACLE (ie, malar rash, butterfly rash)
* Generalized ACLE
* Toxic epidermal necrolysis-like ACLE
presents as erythema in a malar distribution over the cheeks and nose (but sparing the nasolabial folds), which appears after sun exposure
|
|-
|
|discoid lesions
|more inflammatory and which have a tendency to scar
|
|-
|
|Photosensitivity
|common theme for skin lesions associated with SLE
|
|-
|
|oral and/or nasal ulcers
|usually painless
|
|-
|
|Nonscarring alopecia
|may occur at some point during the course of their disease
|
|-
|
|Acute cutaneous lupus erythematosus (ACLE)


●Subacute cutaneous lupus erythematosus (SCLE)
===Extremities<ref name="pmid15580980">{{cite journal |vauthors=Zoma A |title=Musculoskeletal involvement in systemic lupus erythematosus |journal=Lupus |volume=13 |issue=11 |pages=851–3 |year=2004 |pmid=15580980 |doi=10.1191/0961203303lu2021oa |url=}}</ref><ref name="pmid22956550">{{cite journal |vauthors=Gabba A, Piga M, Vacca A, Porru G, Garau P, Cauli A, Mathieu A |title=Joint and tendon involvement in systemic lupus erythematosus: an ultrasound study of hands and wrists in 108 patients |journal=Rheumatology (Oxford) |volume=51 |issue=12 |pages=2278–85 |year=2012 |pmid=22956550 |doi=10.1093/rheumatology/kes226 |url=}}</ref><ref name="pmid19591780">{{cite journal |vauthors=Grossman JM |title=Lupus arthritis |journal=Best Pract Res Clin Rheumatol |volume=23 |issue=4 |pages=495–506 |year=2009 |pmid=19591780 |doi=10.1016/j.berh.2009.04.003 |url=}}</ref><ref name="pmid24862229">{{cite journal |vauthors=Zhu KK, Xu WD, Pan HF, Zhang M, Ni J, Ge FY, Ye DQ |title=The risk factors of avascular necrosis in patients with systemic lupus erythematosus: a meta-analysis |journal=Inflammation |volume=37 |issue=5 |pages=1852–64 |year=2014 |pmid=24862229 |doi=10.1007/s10753-014-9917-y |url=}}</ref><ref name="pmid23731640">{{cite journal |vauthors=Voulgari PV, Kosta P, Argyropoulou MI, Drosos AA |title=Avascular necrosis in a patient with systemic lupus erythematosus |journal=Joint Bone Spine |volume=80 |issue=6 |pages=665 |year=2013 |pmid=23731640 |doi=10.1016/j.jbspin.2013.03.018 |url=}}</ref>===
 
*[[Clubbing]]
•Annular SCLE
*[[Cyanosis]]
 
*[[Muscle weakness|Muscle atrophy or weakness]]
•Papulosquamous SCLE
*[[Livedo reticularis]]
 
**Reddish-cyanotic, reticular pattern on the skin of the arms, legs, and torso, particularly with cold exposure
•Drug-induced SCLE
*[[Arthritis]]
 
**Symmetrical
•Less common variants: erythrodermic, poikilodermatous, erythema multiforme-like (Rowell syndrome), and vesiculobullous annular SCLE
**Polyarticular
 
**Mostly involve knees, carpal joints, and joints of the fingers, especially the proximal [[interphalangeal]] (PIP) joint
●Chronic cutaneous lupus erythematosus (CCLE)
**Decrease  range of motion in affected joints
 
*Joints [[erythema]]
•Discoid lupus erythematosus (DLE)
**Due to [[synovitis]]
 
*Joint effusion
-Localized DLE
*Muscle [[atrophy]]
 
*[[Fasciculations]] in the upper/lower extremity
-Generalized DLE
*[[Claudication]]
 
*Loss of digit or limb
-Hypertrophic DLE
 
•Lupus erythematosus tumidus (LE tumidus)
 
•Lupus profundus (also known as lupus panniculitis)
 
•Chilblain lupus erythematosus (chilblain LE)


•Lichenoid cutaneous lupus erythematosus-lichen planus overlap syndrome (LE-LP overlap syndrome)
===Neuromuscular<ref name="pmid19366083">{{cite journal |vauthors=Cojocaru IM, Cojocaru M, Tănăsescu R, Burcin C, Atanasiu AN, Silosi I |title=Detection of autoantibodies to ribosome P in lupus patients with neurological involvement |journal=Rom J Intern Med |volume=46 |issue=3 |pages=239–42 |year=2008 |pmid=19366083 |doi= |url=}}</ref><ref name="pmid22594009">{{cite journal |vauthors=Madrane S, Ribi C |title=[Central neuropsychiatric involvement in systemic lupus erythematosus] |language=French |journal=Rev Med Suisse |volume=8 |issue=337 |pages=848–53 |year=2012 |pmid=22594009 |doi= |url=}}</ref><ref name="pmid7555923">{{cite journal |vauthors=Sivri A, Hasçelik Z, Celiker R, Başgöze O |title=Early detection of neurological involvement in systemic lupus erythematosus patients |journal=Electromyogr Clin Neurophysiol |volume=35 |issue=4 |pages=195–9 |year=1995 |pmid=7555923 |doi= |url=}}</ref><ref name="pmid19217587">{{cite journal |vauthors=Juncal Gallego L, Almuíña Simón C, Muíños Esparza LF, Díaz Soto R, Ramil Fraga C, Quiroga Ordóñez E |title=[Systemic lupus erythematosus with fulminant neurological involvement] |language=Spanish; Castilian |journal=An Pediatr (Barc) |volume=70 |issue=2 |pages=202–4 |year=2009 |pmid=19217587 |doi=10.1016/j.anpedi.2008.09.009 |url=}}</ref>===
|
*Patient is usually oriented to persons, place, and time based on the disease course
|
*[[Cognitive impairment]]
|-
*[[Hallucination|Hallucinations]]
|
**[[Visual hallucinations|Visual]]
|
**[[Auditory hallucinations|Auditory]]
|
*Memory deficit
|
**Loose associations
|}
**Impoverished thought content
 
**Illogical thinking
====Skin====
**Bizarre disorganised or catatonic behaviour
==Gallery==


<gallery perrow="3">
<gallery perrow="3">
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======Head======
======Head======
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Image:Discoid lupus erythematosus28.jpg|500px|Discoid lupus erythematosus. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>




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Latest revision as of 19:03, 4 August 2017

Systemic lupus erythematosus Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Systemic lupus erythematosus from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Lupus and Quality of Life

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Systemic lupus erythematosus physical examination On the Web

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

Overview

In the earlier stages of the disease, patients appear well, while in the late stages of the disease, patients are clearly ill with multi-organ involvement. The patient may show a wide range of skin manifestations including urticaria, bullous lesions, malar rash, and scarring alopecia. The patient may develop nasal and oral ulcers. Arthritis may lead to a decreased range of motion, joint effusion, and arthralgia. Neurological manifestations including psychosis, cognitive impairment, and hallucinations, may also be present. 

Physical Examination

Appearance of the Patient

  • Patient appears well in the earlier stages of the disease
  • Patient appears ill in the late stages of the disease due to multi-organ involvement

Vital Signs

Skin[1][2][3]

For more pictures of the rash presentation in lupus, click here.

HEENT

Neck[9][10]

Lungs[11][12][13]

Heart[14][10][15]

Abdomen[16][17][18][19]

Extremities[20][21][22][23][24]

Neuromuscular[25][26][27][28]

  • Patient is usually oriented to persons, place, and time based on the disease course
  • Cognitive impairment
  • Hallucinations
  • Memory deficit
    • Loose associations
    • Impoverished thought content
    • Illogical thinking
    • Bizarre disorganised or catatonic behaviour

Gallery

Discoid Lupus Erythematosus
Head
Face
Lupus Erythematosus-Systemic
Face
Extremity
Trunk

Lupus Erythematosus Chronicus Disseminatus Superficialis

Lupus Erythematosus Chronicus Verrucous

Lupus Erythematosus Profundus

Lupus Erythematosus-Subacute Cutaneous Lupus Erythematosus

Lupus Vulgaris

References

  1. ↑ Parodi A, Cozzani E (2014). "Cutaneous manifestations of lupus erythematosus". G Ital Dermatol Venereol. 149 (5): 549–54. PMID 25077888.
  2. ↑ Szczęch J, Rutka M, Samotij D, Zalewska A, Reich A (2016). "Clinical characteristics of cutaneous lupus erythematosus". Postepy Dermatol Alergol. 33 (1): 13–7. doi:10.5114/pdia.2014.44031. PMC 4793050. PMID 26985173.
  3. ↑ Walling HW, Sontheimer RD (2009). "Cutaneous lupus erythematosus: issues in diagnosis and treatment". Am J Clin Dermatol. 10 (6): 365–81. doi:10.2165/11310780-000000000-00000. PMID 19824738.
  4. ↑ Preble JM, Silpa-archa S, Foster CS (2015). "Ocular involvement in systemic lupus erythematosus". Curr Opin Ophthalmol. 26 (6): 540–5. doi:10.1097/ICU.0000000000000209. PMID 26367085.
  5. ↑ Silpa-archa S, Lee JJ, Foster CS (2016). "Ocular manifestations in systemic lupus erythematosus". Br J Ophthalmol. 100 (1): 135–41. doi:10.1136/bjophthalmol-2015-306629. PMID 25904124.
  6. ↑ Robson AK, Burge SM, Millard PR (1992). "Nasal mucosal involvement in lupus erythematosus". Clin Otolaryngol Allied Sci. 17 (4): 341–3. PMID 1526055.
  7. ↑ Anyanwu CO, Ang CC, Werth VP (2013). "Oral mucosal involvement in bullous lupus". Arthritis Rheum. 65 (10): 2622. doi:10.1002/art.38051. PMC 4333153. PMID 23780804.
  8. ↑ Ranginwala AM, Chalishazar MM, Panja P, Buddhdev KP, Kale HM (2012). "Oral discoid lupus erythematosus: A study of twenty-one cases". J Oral Maxillofac Pathol. 16 (3): 368–73. doi:10.4103/0973-029X.102487. PMC 3519212. PMID 23248469.
  9. ↑ Melikoglu MA, Melikoglu M (2008). "The clinical importance of lymphadenopathy in systemic lupus erythematosus". Acta Reumatol Port. 33 (4): 402–6. PMID 19107085.
  10. ↑ 10.0 10.1 Sacre K, Escoubet B, Pasquet B, Chauveheid MP, Zennaro MC, Tubach F, Papo T (2014). "Increased arterial stiffness in systemic lupus erythematosus (SLE) patients at low risk for cardiovascular disease: a cross-sectional controlled study". PLoS ONE. 9 (4): e94511. doi:10.1371/journal.pone.0094511. PMC 3983200. PMID 24722263.
  11. ↑ Torre O, Harari S (2011). "Pleural and pulmonary involvement in systemic lupus erythematosus". Presse Med. 40 (1 Pt 2): e19–29. doi:10.1016/j.lpm.2010.11.004. PMID 21194884.
  12. ↑ Salvati F (2015). "[The involvement of pulmonary interstitial tissue in multisystemic lupus erythematosus: interdisciplinarity and role of the pneumologists]". Clin Ter (in Italian). 166 (5): 205–7. PMID 26550810.
  13. ↑ Alamoudi OS, Attar SM (2015). "Pulmonary manifestations in systemic lupus erythematosus: association with disease activity". Respirology. 20 (3): 474–80. doi:10.1111/resp.12473. PMC 4418345. PMID 25639532.
  14. ↑ Mak A, Kow NY (2014). "Imbalance between endothelial damage and repair: a gateway to cardiovascular disease in systemic lupus erythematosus". Biomed Res Int. 2014: 178721. doi:10.1155/2014/178721. PMC 3984775. PMID 24790989.
  15. ↑ Canpolat N, Kasapcopur O, Caliskan S, Gokalp S, Bor M, Tasdemir M, Sever L, Arisoy N (2013). "Ambulatory blood pressure and subclinical cardiovascular disease in patients with juvenile-onset systemic lupus erythematosus". Pediatr. Nephrol. 28 (2): 305–13. doi:10.1007/s00467-012-2317-3. PMID 23052654.
  16. ↑ Tian XP, Zhang X (2010). "Gastrointestinal involvement in systemic lupus erythematosus: insight into pathogenesis, diagnosis and treatment". World J. Gastroenterol. 16 (24): 2971–7. PMC 2890936. PMID 20572299.
  17. ↑ Alves SC, Fasano S, Isenberg DA (2016). "Autoimmune gastrointestinal complications in patients with systemic lupus erythematosus: case series and literature review". Lupus. 25 (14): 1509–1519. doi:10.1177/0961203316655210. PMID 27329649.
  18. ↑ Fawzy M, Edrees A, Okasha H, El Ashmaui A, Ragab G (2016). "Gastrointestinal manifestations in systemic lupus erythematosus". Lupus. 25 (13): 1456–1462. doi:10.1177/0961203316642308. PMID 27055518.
  19. ↑ Li Z, Xu D, Wang Z, Wang Y, Zhang S, Li M, Zeng X (2017). "Gastrointestinal system involvement in systemic lupus erythematosus". Lupus: 961203317707825. doi:10.1177/0961203317707825. PMID 28523968.
  20. ↑ Zoma A (2004). "Musculoskeletal involvement in systemic lupus erythematosus". Lupus. 13 (11): 851–3. doi:10.1191/0961203303lu2021oa. PMID 15580980.
  21. ↑ Gabba A, Piga M, Vacca A, Porru G, Garau P, Cauli A, Mathieu A (2012). "Joint and tendon involvement in systemic lupus erythematosus: an ultrasound study of hands and wrists in 108 patients". Rheumatology (Oxford). 51 (12): 2278–85. doi:10.1093/rheumatology/kes226. PMID 22956550.
  22. ↑ Grossman JM (2009). "Lupus arthritis". Best Pract Res Clin Rheumatol. 23 (4): 495–506. doi:10.1016/j.berh.2009.04.003. PMID 19591780.
  23. ↑ Zhu KK, Xu WD, Pan HF, Zhang M, Ni J, Ge FY, Ye DQ (2014). "The risk factors of avascular necrosis in patients with systemic lupus erythematosus: a meta-analysis". Inflammation. 37 (5): 1852–64. doi:10.1007/s10753-014-9917-y. PMID 24862229.
  24. ↑ Voulgari PV, Kosta P, Argyropoulou MI, Drosos AA (2013). "Avascular necrosis in a patient with systemic lupus erythematosus". Joint Bone Spine. 80 (6): 665. doi:10.1016/j.jbspin.2013.03.018. PMID 23731640.
  25. ↑ Cojocaru IM, Cojocaru M, Tănăsescu R, Burcin C, Atanasiu AN, Silosi I (2008). "Detection of autoantibodies to ribosome P in lupus patients with neurological involvement". Rom J Intern Med. 46 (3): 239–42. PMID 19366083.
  26. ↑ Madrane S, Ribi C (2012). "[Central neuropsychiatric involvement in systemic lupus erythematosus]". Rev Med Suisse (in French). 8 (337): 848–53. PMID 22594009.
  27. ↑ Sivri A, Hasçelik Z, Celiker R, Başgöze O (1995). "Early detection of neurological involvement in systemic lupus erythematosus patients". Electromyogr Clin Neurophysiol. 35 (4): 195–9. PMID 7555923.
  28. ↑ Juncal Gallego L, Almuíña Simón C, Muíños Esparza LF, Díaz Soto R, Ramil Fraga C, Quiroga Ordóñez E (2009). "[Systemic lupus erythematosus with fulminant neurological involvement]". An Pediatr (Barc) (in Spanish; Castilian). 70 (2): 202–4. doi:10.1016/j.anpedi.2008.09.009. PMID 19217587.
  29. ↑ 29.00 29.01 29.02 29.03 29.04 29.05 29.06 29.07 29.08 29.09 29.10 29.11 29.12 29.13 29.14 29.15 29.16 29.17 29.18 29.19 29.20 29.21 29.22 29.23 29.24 29.25 29.26 29.27 29.28 29.29 29.30 29.31 29.32 29.33 29.34 29.35 29.36 29.37 29.38 29.39 29.40 29.41 29.42 29.43 29.44 29.45 29.46 29.47 29.48 29.49 29.50 29.51 29.52 29.53 29.54 29.55 29.56 29.57 29.58 29.59 29.60 29.61 29.62 29.63 29.64 29.65 29.66 29.67 29.68 29.69 29.70 29.71 29.72 29.73 29.74 29.75 29.76 29.77 "Dermatology Atlas".
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