Systemic lupus erythematosus physical examination: Difference between revisions

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==Physical Examination==
==Physical Examination==
Some signs to look out for are:
===Appearance of the Patient===
* Discoid skin lesions
*This section should give a general description of what a patient with the disease you are describing may look like.
* Erythematous macules
*If patients typically appear normal, you may write: Patients are usually well-appearing.
* Mucosal lesions
*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)
* Photo distributed rash
*For an example of the appearance of a patient section in the physical examination page, click [[Stomach cancer physical examination|here]].
* [[Raynaud phenomenon]]
===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>
*High-grade / low-grade fever
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[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===
*[[Cyanosis]]
*[[Jaundice]]
*[[Pallor]]
*Bruises
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">
 
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 S1.2C 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
|frequently associated with depression, sleep disturbances, and concomitant fibromyalgia
|-
|
|Fever
|a manifestation of active disease-lupus flare, especially within short-term evolution of the disease 14530779
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
|
|-
|
|Myalgia
muscle tenderness
 
muscle weakness
|may be first complaint and initial reason for the patient to seeks medical attention
May happen as a result of treatment with glucocorticoids or glucocorticoid withdrawal
|perivascular and perifascicular mononuclear cell infiltrates in 25 percent of patients
muscle atrophy, microtubular inclusions, mononuclear infiltrate, fiber necrosis, and, occasionally, vacuolated muscle fibers  2319520
|-
|
|Weight change
|
* 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
|
|}


====Skin====
====Skin====


<gallery perRow="3">
<gallery perrow="3">
Image:Systemic lupus erythematosus 052.jpg|Skin: Lupus, systemic erythematosus; Discoid skin lesion in patient with SLE. <SMALL><SMALL>''[http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
Image:Systemic lupus erythematosus 052.jpg|Skin: Lupus, systemic erythematosus; Discoid skin lesion in patient with SLE. <SMALL><SMALL>''[http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
Image:Systemic lupus erythematosus 053.jpg|Skin: ulcer, necrotic; lupus anticoagulant in thigh. [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
Image:Systemic lupus erythematosus 053.jpg|Skin: ulcer, necrotic; lupus anticoagulant in thigh. [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>

Revision as of 17:35, 15 June 2017

Systemic lupus erythematosus Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2] Kiran Singh, M.D. [3]

Overview

Physical Examination

Appearance of the Patient

  • This section should give a general description of what a patient with the disease you are describing may look like.
  • If patients typically appear normal, you may write: Patients are usually well-appearing.
  • 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 here.

Vital Signs

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.

  • High-grade / low-grade fever
  • Hypothermia / hyperthermia may be present
  • Tachycardia with regular pulse or (ir)regularly irregular pulse
  • 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

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)

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

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
  • S1
  • S2
  • S3
  • S4
  • 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

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

Write additional pathognomonic findings, such as discharge that resembles cottage cheese for C. albicans vulvovaginitis / fish-odor for T. vaginalis ifnection

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)

Constitutional symptoms Fatigue the most common complaint 11085805

multidimensional phenomenon due to different factors 7779127

does not correlate with disease activity 9598886

frequently associated with depression, sleep disturbances, and concomitant fibromyalgia
Fever a manifestation of active disease-lupus flare, especially within short-term evolution of the disease 14530779

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

Myalgia

muscle tenderness

muscle weakness

may be first complaint and initial reason for the patient to seeks medical attention

May happen as a result of treatment with glucocorticoids or glucocorticoid withdrawal

perivascular and perifascicular mononuclear cell infiltrates in 25 percent of patients

muscle atrophy, microtubular inclusions, mononuclear infiltrate, fiber necrosis, and, occasionally, vacuolated muscle fibers 2319520

Weight change
  • 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

Skin

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. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 1.41 1.42 1.43 1.44 1.45 1.46 1.47 1.48 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.74 1.75 1.76 1.77 "Dermatology Atlas".
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