Antiphospholipid syndrome physical examination: Difference between revisions

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{{Antiphospholipid syndrome}}
{{Antiphospholipid syndrome}}
{{CMG}}{{AE}}{{FT}}
{{CMG}}; {{AE}}{{FT}}


==Overview==
==Overview==
Physical examination shows no pathognomonic physical findings of antiphospholipid syndrome (APS); however, abnormal features may be found on examination that are related to infarction or ischemia of the skin, viscera, or the central nervous system leading to cutaneous and neurological manifestations.


==Physical Examination==
==Physical Examination==
* Physical examination of patients with [disease name] is usually normal.
Physical examination shows no pathognomonic physical findings of APS; however, abnormal features may be found on examination that are related to infarction or ischemia of the skin, viscera, or the central nervous system leading to cutaneous and neurological manifestations.
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 [disease name] usually appear [general appearance].  
*Patients with APS usually appear normal.  


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


*High-grade / low-grade fever
*Low-grade fever may be present in case of infectious cause of APS.
*[[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]]


===Cutaneous manifestations===
===Cutaneous manifestations===
* Skin examination of patients with APS is usually positive for:
Skin examination of patients with APS is usually positive for:<ref name="pmid11953980">{{cite journal| author=Cervera R, Piette JC, Font J, Khamashta MA, Shoenfeld Y, Camps MT et al.| title=Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients. | journal=Arthritis Rheum | year= 2002 | volume= 46 | issue= 4 | pages= 1019-27 | pmid=11953980 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11953980  }} </ref><ref name="pmid20822807">{{cite journal| author=Ruiz-Irastorza G, Crowther M, Branch W, Khamashta MA| title=Antiphospholipid syndrome. | journal=Lancet | year= 2010 | volume= 376 | issue= 9751 | pages= 1498-509 | pmid=20822807 | doi=10.1016/S0140-6736(10)60709-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20822807  }} </ref><ref name="pmid27334977">{{cite journal| author=Negrini S, Pappalardo F, Murdaca G, Indiveri F, Puppo F| title=The antiphospholipid syndrome: from pathophysiology to treatment. | journal=Clin Exp Med | year= 2017 | volume= 17 | issue= 3 | pages= 257-267 | pmid=27334977 | doi=10.1007/s10238-016-0430-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27334977  }} </ref>
*Livedo reticularis  
*[[Venous thromboembolism]]
*Pupura
*[[Livedoid vasculitis|Livedo reticularis]]
*[[Purpura]]
*Superficial thrombophelibitis
*Superficial thrombophelibitis
*Leg ulcers
*Leg ulcers
*Splinter hemorrhages
*[[Splinter hemorrhage|Splinter]] [[Bleeding|hemorrhages]]
*Gangrene of the distal extremities
*[[Gangrene]] of the distal extremities
*Leg swelling  
*Leg swelling
<gallery widths="150px">
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
Abnormal fundoscopic examination findings:<ref name="pmid17101948">{{cite journal| author=Tektonidou MG, Varsou N, Kotoulas G, Antoniou A, Moutsopoulos HM| title=Cognitive deficits in patients with antiphospholipid syndrome: association with clinical, laboratory, and brain magnetic resonance imaging findings. | journal=Arch Intern Med | year= 2006 | volume= 166 | issue= 20 | pages= 2278-84 | pmid=17101948 | doi=10.1001/archinte.166.20.2278 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17101948  }} </ref>
OR
*[[Retinal]] artery occlusion findings
* Abnormalities of the head/hair may include ___
*Retinal vein [[thrombosis]] findings
* 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===
* Neck examination of patients with [disease name] is usually normal.
* Neck examination of patients with APS can show [[lymphadenopathy]].
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===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
Pulmonary examination of patients with APS may show the following findings:
OR
*[[Tachypnea]] in case of pulmonary embolism.
* 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===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
* Cardiovascular examination of patients with APS shows findings consistent with
OR
* Heart valve disease
*Chest tenderness upon palpation
* [[Pericarditis]]
*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 examination of patients with [disease name] is usually normal.
* [[Hepatomegaly]]<ref name="pmid25641203">{{cite journal| author=Abreu MM, Danowski A, Wahl DG, Amigo MC, Tektonidou M, Pacheco MS et al.| title=The relevance of "non-criteria" clinical manifestations of antiphospholipid syndrome: 14th International Congress on Antiphospholipid Antibodies Technical Task Force Report on Antiphospholipid Syndrome Clinical Features. | journal=Autoimmun Rev | year= 2015 | volume= 14 | issue= 5 | pages= 401-14 | pmid=25641203 | doi=10.1016/j.autrev.2015.01.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25641203  }} </ref>
* [[Splenomegaly]]  


OR
*[[Abdominal tenderness]] in the lower abdominal quadrant in case of miscarriage or fetal loss.
*[[Abdominal distention]]
*[[Rebound tenderness]]  
*[[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
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with APS is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
* Genitourinary examination of patients with APS is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
* Neurological exam findings consistent with [[stroke]] or [[Transient ischemic attack|transient]] ischemic attack.<ref name="pmid28769114">{{cite journal| author=Sciascia S, Amigo MC, Roccatello D, Khamashta M| title=Diagnosing antiphospholipid syndrome: 'extra-criteria' manifestations and technical advances. | journal=Nat Rev Rheumatol | year= 2017 | volume= 13 | issue= 9 | pages= 548-560 | pmid=28769114 | doi=10.1038/nrrheum.2017.124 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28769114  }} </ref>
OR
* [[Migraine]]
*Patient is usually oriented to persons, place, and time
* [[Multi-infarct dementia|Vascular dementia]]
* Altered mental status
* [[Pre-eclampsia]] or [[eclampsia]]
* 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)


==References==
==References==

Latest revision as of 20:26, 24 April 2018

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

Overview

Physical examination shows no pathognomonic physical findings of antiphospholipid syndrome (APS); however, abnormal features may be found on examination that are related to infarction or ischemia of the skin, viscera, or the central nervous system leading to cutaneous and neurological manifestations.

Physical Examination

Physical examination shows no pathognomonic physical findings of APS; however, abnormal features may be found on examination that are related to infarction or ischemia of the skin, viscera, or the central nervous system leading to cutaneous and neurological manifestations.

Appearance of the Patient

  • Patients with APS usually appear normal.

Vital Signs

  • Low-grade fever may be present in case of infectious cause of APS.

Cutaneous manifestations

Skin examination of patients with APS is usually positive for:[1][2][3]

HEENT

Abnormal fundoscopic examination findings:[4]

Neck

Lungs

Pulmonary examination of patients with APS may show the following findings:

Heart

  • Cardiovascular examination of patients with APS shows findings consistent with
  • Heart valve disease
  • Pericarditis

Abdomen

Back

  • Back examination of patients with APS is usually normal.

Genitourinary

  • Genitourinary examination of patients with APS is usually normal.

Neuromuscular

References

  1. ↑ Cervera R, Piette JC, Font J, Khamashta MA, Shoenfeld Y, Camps MT; et al. (2002). "Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients". Arthritis Rheum. 46 (4): 1019–27. PMID 11953980.
  2. ↑ Ruiz-Irastorza G, Crowther M, Branch W, Khamashta MA (2010). "Antiphospholipid syndrome". Lancet. 376 (9751): 1498–509. doi:10.1016/S0140-6736(10)60709-X. PMID 20822807.
  3. ↑ Negrini S, Pappalardo F, Murdaca G, Indiveri F, Puppo F (2017). "The antiphospholipid syndrome: from pathophysiology to treatment". Clin Exp Med. 17 (3): 257–267. doi:10.1007/s10238-016-0430-5. PMID 27334977.
  4. ↑ Tektonidou MG, Varsou N, Kotoulas G, Antoniou A, Moutsopoulos HM (2006). "Cognitive deficits in patients with antiphospholipid syndrome: association with clinical, laboratory, and brain magnetic resonance imaging findings". Arch Intern Med. 166 (20): 2278–84. doi:10.1001/archinte.166.20.2278. PMID 17101948.
  5. ↑ Abreu MM, Danowski A, Wahl DG, Amigo MC, Tektonidou M, Pacheco MS; et al. (2015). "The relevance of "non-criteria" clinical manifestations of antiphospholipid syndrome: 14th International Congress on Antiphospholipid Antibodies Technical Task Force Report on Antiphospholipid Syndrome Clinical Features". Autoimmun Rev. 14 (5): 401–14. doi:10.1016/j.autrev.2015.01.002. PMID 25641203.
  6. ↑ Sciascia S, Amigo MC, Roccatello D, Khamashta M (2017). "Diagnosing antiphospholipid syndrome: 'extra-criteria' manifestations and technical advances". Nat Rev Rheumatol. 13 (9): 548–560. doi:10.1038/nrrheum.2017.124. PMID 28769114.
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