Toxic shock syndrome physical examination: Difference between revisions

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{{CMG}}{{AE}}{{MIR}}
{{CMG}}{{AE}}{{MIR}}


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].
== Overview ==
Patients with [[toxic shock syndrome]] (TSS) usually appear with [[shock]]. [[Physical examination]] of patients with TSS is usually remarkable for [[hypotension]], [[fever]], and diffuse [[erythroderma]].


Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
The presence of [[desquamation]] on [[physical examination]] is highly suggestive of TSS.
 
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].


==Physical Examination==
==Physical Examination==


===Appearance of the Patient===
===Appearance of the Patient===
*Toxic shock syndrome(TSS) is presented by its shock symptoms, means the patient is always as they  .
*TSS is presented by its [[shock]] symptoms.
*If patients typically appear normal, you may write: Patients are usually well-appearing.
*May be ill appearing in the early stages of the disease, progress to confusion and change in mental status by disease progress.
*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===
* High grade [[Fever]]
* High grade [[Fever]]
* [[Hypotension]]: [[systolic blood pressure]] of ≤90 mmHg for adults or less than fifth percentile by age for children <16 years of age, which may be unresponsive to fluid infusion even large amounts of [[isotonic]] [[intravenous fluids]]
* [[Hypotension]]: [[Systolic blood pressure]] of ≤90 mmHg for adults or less than fifth percentile by age for children <16 years of age, which may be unresponsive to [[Fluid balance|fluid infusion]] even large amounts of [[isotonic]] [[intravenous fluids]]
* [[Tachycardia]] (as a result of shock and hypotension)
* [[Tachycardia]]: As a result of [[shock]] and [[hypotension]]
* [[Tachypnea]]: may be pressent as a result of pulmonary edema secondary to shock
* [[Tachypnea]]: May be pressent as a result of [[pulmonary edema]] secondary to [[shock]]
*[[Tachycardia]]
*[[Tachycardia]]
*Tachypnea
*[[Tachypnea]]
===Skin===
===Skin===
* Diffuse [[Pruritic disorders|pruritic]] [[maculopapular]] [[rash]] with palm and soles [[desquamation]]
* Diffuse [[Pruritic disorders|pruritic]] [[maculopapular]] [[rash]] with palm and soles [[desquamation]]
* [[Erythroderma]]
* [[Erythroderma]]
* Superficial [[Ulcer|ulcerations]]
* Superficial [[Ulcer|ulcerations]]
* [[petechiae]], [[vesicles]], and bullae
* [[Petechiae]], [[vesicles]], and bullae (specially in Streptococcal TSS)
* [[Skin]] [[desquamation]] (apears weeks after the disease onset)
* [[Skin]] [[desquamation]] (apears weeks after disease onset)
* [[Edema|Non-pitting edema]]
* [[Edema|Non-pitting edema]]
* Hair and nail loss<ref name="urlTintinallis Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books">{{cite web |url=https://books.google.com/books?id=FNKLCgAAQBAJ&q=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&dq=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&hl=en&sa=X&ved=0ahUKEwjlq-LXoODTAhVF7CYKHQ3aDkoQ6AEIJzAA |title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books |format= |work= |accessdate=}}</ref><ref name="pmid7282746">{{cite journal |vauthors=Chesney RW, Chesney PJ, Davis JP, Segar WE |title=Renal manifestations of the staphylococcal toxic-shock syndrome |journal=Am. J. Med. |volume=71 |issue=4 |pages=583–8 |year=1981 |pmid=7282746 |doi= |url=}}</ref><ref name="pmid2928649">{{cite journal |vauthors=Olson RD, Stevens DL, Melish ME |title=Direct effects of purified staphylococcal toxic shock syndrome toxin 1 on myocardial function of isolated rabbit atria |journal=Rev. Infect. Dis. |volume=11 Suppl 1 |issue= |pages=S313–5 |year=1989 |pmid=2928649 |doi= |url=}}</ref>.
* Hair and nail loss<ref name="urlTintinallis Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books">{{cite web |url=https://books.google.com/books?id=FNKLCgAAQBAJ&q=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&dq=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&hl=en&sa=X&ved=0ahUKEwjlq-LXoODTAhVF7CYKHQ3aDkoQ6AEIJzAA |title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books |format= |work= |accessdate=}}</ref><ref name="pmid7282746">{{cite journal |vauthors=Chesney RW, Chesney PJ, Davis JP, Segar WE |title=Renal manifestations of the staphylococcal toxic-shock syndrome |journal=Am. J. Med. |volume=71 |issue=4 |pages=583–8 |year=1981 |pmid=7282746 |doi= |url=}}</ref><ref name="pmid2928649">{{cite journal |vauthors=Olson RD, Stevens DL, Melish ME |title=Direct effects of purified staphylococcal toxic shock syndrome toxin 1 on myocardial function of isolated rabbit atria |journal=Rev. Infect. Dis. |volume=11 Suppl 1 |issue= |pages=S313–5 |year=1989 |pmid=2928649 |doi= |url=}}</ref>.
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*[[Cyanosis]]  
*[[Cyanosis]]  
===HEENT===
===HEENT===
*Ophthalmoscopic exam may be abnormal with findings of [[Conjunctiva|Conjunctival]]-[[Sclera|scleral hemorrhage]]
*Ophthalmoscopic exam may be abnormal with findings of [[Conjunctiva|conjunctival]]-[[Sclera|scleral hemorrhage]]
*[[hyperemia]] of the [[vaginal]] and [[oropharyngeal]] [[mucosa]]
*[[Hyperemia]] of [[oropharyngeal]] [[mucosa]]
*
*
*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
*
*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===
===Lungs===
*Asymmetric chest expansion / Decreased chest expansion
*[[Rale|Wet rales]] due to [[pulmonary edema]] complication
*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===
===Heart===
*Chest tenderness upon palpation
*Possibly a [[diastolic]] [[Gallops and Extra Heart Sounds|gallop]] ([[S3]]) due to [[pulmonary edema]]
*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 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===
===Extremities===
*[[Edema|Non-pitting edema]] (can develop as a result of increases in [[interstitial fluid]])
*[[Edema|Non-pitting edema]] (can develop as a result of increases in [[interstitial fluid]])
*[[Muscle cramps|Muscle cramps (complication)]]
*
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
===Neuromuscular===
===Neuromuscular===
<span> </span>
*Patient is usually oriented but if the disease is not diagnosed, it can lead to altered [[mental status]] and [[confusion]]
*Patient is usually oriented to persons, place, and time
*[[Hyporeflexia]] can be seen as a result of associated [[hypocalcemia]]/ [[hypophosphatemia]]
*Altered mental status
*[[Muscle cramps|Muscle cramps]] (as a result of [[hypocalcemia]], a contributing complication of [[renal failure]])
*Glasgow coma scale is ___ / 15
*[[Seizure]]
*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)
*
 
===Neuropsychologic===
* [[Cerebral edema]]
* [[Seizure activity|Seizure]] activity
* [[Headaches]], [[memory loss]],[[disorientation]] and poor [[concentration]] ,
* [[Somnolence]], [[irritability]], [[agitation]], and [[Hallucination|hallucinations]]  
* [[Confusion]] without any focal neurological findings
 
===Gastrointestinal===
* [[Vomiting]]
* Watery [[Diarrhea]]
* [[Hepatic failure|Hepatic Failure]]: Which may present with [[hepatomegaly]], [[hypoalbuminemia]], [[Edema|non-pitting edema]]
 
=== Renal ===
* [[Renal failure|Prerenal failure]]: Decrease in urinary output, due to [[dehydration]] and [[shock]]
* [[Metabolic Control Analysis|Metabolic abnormalities]] related to RF such as [[hypocalcemia]], [[hyponatremia]], and [[hypophosphatemia]] and their related signs and symptoms
 
=== Cardiopulmonary ===
* [[Pleural effusion|Pleural effusions]]
* [[Pulmonary edema]]
* [[Cardiac dysfunction]]
 
===Skin and [[moucosa]]===
*
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 23:38, 13 May 2017

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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

Patients with toxic shock syndrome (TSS) usually appear with shock. Physical examination of patients with TSS is usually remarkable for hypotension, fever, and diffuse erythroderma.

The presence of desquamation on physical examination is highly suggestive of TSS.

Physical Examination

Appearance of the Patient

  • TSS is presented by its shock symptoms.
  • May be ill appearing in the early stages of the disease, progress to confusion and change in mental status by disease progress.

Vital Signs

Skin

HEENT

Lungs

Heart

Extremities

Neuromuscular

References

  1. ↑ "Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books".
  2. ↑ Chesney RW, Chesney PJ, Davis JP, Segar WE (1981). "Renal manifestations of the staphylococcal toxic-shock syndrome". Am. J. Med. 71 (4): 583–8. PMID 7282746.
  3. ↑ Olson RD, Stevens DL, Melish ME (1989). "Direct effects of purified staphylococcal toxic shock syndrome toxin 1 on myocardial function of isolated rabbit atria". Rev. Infect. Dis. 11 Suppl 1: S313–5. PMID 2928649.


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