Behçet's disease physical examination: Difference between revisions

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{{Behcet's disease}}  
{{Behçet's disease}}  


{{CMG}}; {{AE}} {{HQ}}
{{CMG}}; {{AE}} {{HQ}}, {{JH}}


==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 Behçet disease usually appear normal. Vital signs of patients with Behçet disease are usually normal. The presence of [[Oral ulcer|mouth sores]], [[Genital ulcer|genital ulcers]], and [[Visual impairment|vision problems]] on physical examination are diagnostic of Behçet disease. [[Skin]] examination of patients with Behçet disease shows [[erythema nodosum]] [[Lesion|lesions]] typically occur on the [[Limb (anatomy)|extremities]], especially the lower legs, but they can also be observed on the [[face]], [[neck]], and [[buttocks]]. The [[Lesion|lesions]] are [[Pain|painful]] and resolve spontaneously, although some may [[Ulcer|ulcerate]] or leave [[hyperpigmentation]]. A [[folliculitis]] like [[rash]], resembling [[Acne vulgaris|acne]] [[Acne Vulgaris|vulgaris]], appears on the [[face]], [[neck]], [[chest]], [[Human back|back]], and [[Stress fracture|hairline]] of patients. Some lesions become more [[Rash|pustular]]; 24-48 hours after a [[Sterility|sterile]] [[needle]] prick, some patients develop [[erythema]] with a [[Nodule (medicine)|nodule]] or [[Abscess|pustule]] at the prick site. Ophthalmoscopic exam may be abnormal with findings of [[retinal]] [[vasculitis]], and vaso-occlusive [[Lesion|lesions]]. [[Uveitis]] of anterior and posterior chambers diagnosed with [[Slit lamp|slit-lamp]] examination. [[Erythema|Erythematous]] throat with [[Tonsillitis|tonsillar]] [[Edema|swelling]], and [[Exudate|exudates]]. [[Ulcer|Ulcers]] 2-15 mm in diameter, with a [[Necrosis|necrotic]] center and surrounding red rim. A white or yellow pseudomembrane covers the surface of the [[ulcer]]. The [[Ulcer|ulcers]] are typically [[Pain|painful]], nonscarring, and found on the lips, [[buccal mucosa]], [[tongue]], [[Tonsil|tonsils]], and [[larynx]]. Most last 7-14 days and occur in crops. [[Hypopyon]] may be observed in the [[anterior chamber]]. [[Genitourinary system|Genitourinary]] examination of patients with Behçet disease will show [[Ulcer|ulcers]] on the [[scrotum]] and [[vulva]], [[Pain|painful]] and heal with [[Scar|scarring]]. [[Sex organ|Genital]] [[Ulcer|ulcerations]] tend to be deeper and larger than the [[oral lesions]]. Females can have asymptomatic [[Ulcer|ulcers]]. [[Neuromuscular junction|Neuromuscular]] examination of patients with Behçet disease will show [[CNS]] involvement in 25% of the cases. [[Immune-mediated disease|Immune-mediated]] [[meningoencephalitis]] predominantly involves the [[Brain stem|brainstem]]. [[Meningitis]], [[encephalitis]], focal [[Neurology|neurological]] deficits, and [[psychiatric]] symptoms can be present. Irreversible [[dementia]] can occur.  
 
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==
* Physical examination of patients with [disease name] is usually normal.
Physical examination of patients with Behçet disease is usually remarkable for: [[Skin lesion|skin lesions]], [[Genital ulcer|genital lesions]], and [[Neuromuscular disease|neuromuscular]] complications.<ref name="pmid14727454">{{cite journal| author=Zouboulis CC, Vaiopoulos G, Marcomichelakis N, Palimeris G, Markidou I, Thouas B et al.| title=Onset signs, clinical course, prognosis, treatment and outcome of adult patients with Adamantiades-Behçet's disease in Greece. | journal=Clin Exp Rheumatol | year= 2003 | volume= 21 | issue= 4 Suppl 30 | pages= S19-26 | pmid=14727454 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14727454  }} </ref><ref name="pmid19026127">{{cite journal| author=Moses Alder N, Fisher M, Yazici Y| title=Behçet's syndrome patients have high levels of functional disability, fatigue and pain as measured by a Multi-dimensional Health Assessment Questionnaire (MDHAQ). | journal=Clin Exp Rheumatol | year= 2008 | volume= 26 | issue= 4 Suppl 50 | pages= S110-3 | pmid=19026127 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19026127  }} </ref><ref name="pmid1970380">{{cite journal| author=| title=Criteria for diagnosis of Behçet's disease. International Study Group for Behçet's Disease. | journal=Lancet | year= 1990 | volume= 335 | issue= 8697 | pages= 1078-80 | pmid=1970380 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1970380  }} </ref>
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 Behçet disease usually appear normal.  


===Vital Signs===
===Vital Signs===
 
*Vital signs of patients with Behçet disease are usually normal.
*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===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
* [[Skin]] examination of patients with Behçet disease shows the following:
OR
**[[Erythema nodosum]] lesions typically occur on the [[Limb (anatomy)|extremities]], especially the lower [[Leg|legs]], but they can also be observed on the [[face]], [[neck]], and [[buttocks]]
*[[Cyanosis]]
**The [[Lesion|lesions]] are [[Pain|painful]] and resolve spontaneously, although some may [[Ulcer|ulcerate]] or leave [[hyperpigmentation]]
*[[Jaundice]]
**A [[folliculitis]] like [[rash]], resembling [[acne vulgaris]], appears on the [[face]], [[neck]], [[chest]], [[Human back|back]], and hairline of patients
* [[Pallor]]
**Some lesions become more [[Rash|pustular]]; 24-48 hours after a [[Sterility|sterile]] needle prick, some patients develop [[erythema]] with a [[Nodule (medicine)|nodule]] or [[Abscess|pustule]] at the prick site
* Bruises
Erythema nodosum lesions typically occur on the extremities, especially the lower legs, but they can also be observed on the face, neck, and buttocks. The lesions are painful and resolve spontaneously, although some may ulcerate or leave hyperpigmentation. A folliculitislike rash, resembling acne vulgaris, appears on the face, neck, chest, back, and hairline of patients. Some lesions become more pustular; 24-48 hours after a sterile needle prick, some patients develop erythema with a nodule or pustule at the prick site. This pathergy response is commonly observed in patients from Asia and the Middle East and is uncommon in northern European and North American patients.


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
*Ophthalmoscopic exam may be abnormal with findings of [[retinal]] [[vasculitis]], vaso-occlusive lesions:
OR
**[[Uveitis]] of anterior and posterior chambers diagnosed with [[Slit lamp|slit-lamp]] examination<ref name="pmid12544711">{{cite journal| author=Kural-Seyahi E, Fresko I, Seyahi N, Ozyazgan Y, Mat C, Hamuryudan V et al.| title=The long-term mortality and morbidity of Behçet syndrome: a 2-decade outcome survey of 387 patients followed at a dedicated center. | journal=Medicine (Baltimore) | year= 2003 | volume= 82 | issue= 1 | pages= 60-76 | pmid=12544711 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12544711  }} </ref>
* Abnormalities of the head/hair may include ___
* [[Erythema|Erythematous]] throat with [[Tonsillitis|tonsillar]] [[Edema|swelling]], and [[Exudate|exudates]]:
* Evidence of trauma
**[[Ulcer|Ulcers]] 2-15 mm in diameter, with a [[Necrosis|necrotic]] center and surrounding red rim
* Icteric sclera
**A white or yellow pseudomembrane covers the surface of the [[ulcer]]
* [[Nystagmus]]  
**The [[Ulcer|ulcers]] are typically [[Pain|painful]], nonscarring, and found on the lips, [[buccal mucosa]], [[tongue]], [[Tonsil|tonsils]], and [[larynx]]
* Extra-ocular movements may be abnormal
**Most last 7-14 days and occur in crops
*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


Uveitis can occur in both the anterior and posterior chambers of the eye. [13] Frank pus (hypopyon) may be observed in the anterior chamber. Retinal vasculitis is the most serious ocular finding. Vaso-occlusive lesions of the retinal vessels may cause a progressive decreased visual acuity. A slit lamp examination is necessary for diagnosis of uveitis, and fluorescein angiography is useful to identify retinal lesions.
*[[Hypopyon]] may be observed in the [[anterior chamber]].


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
* Neck examination of patients with Behçet disease is usually normal.
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 Behçet disease is usually normal.
OR
* 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.
*[[Circulatory system|Cardiovascular]] examination of patients with Behçet disease is usually normal.
OR
*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 examination of patients with [disease name] is usually normal.
* Abdominal examination of patients with Behçet disease is usually normal.
 
OR
*[[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===
===Back===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with Behçet disease 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 Behçet disease will show:
OR
**[[Ulcer|Ulcers]] on the [[scrotum]] and [[vulva]], [[Pain|painful]] and heal with [[Scar|scarring]]
*A pelvic/adnexal mass may be palpated
**[[Sex organ|Genital]] [[Ulcer|ulcerations]] tend to be deeper and larger than the oral lesions
*Inflamed mucosa
**[[Female|Females]] can have asymptomatic [[Ulcer|ulcers]]
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
* [[Neuromuscular]] examination of patients with Behçet disease will show the following:
OR
**[[CNS]] involvement occurs in 25% of the cases
*Patient is usually oriented to persons, place, and time
**[[Immune-mediated disease|Immune-mediated]] [[meningoencephalitis]] predominantly involves the [[brain stem]]
* Altered mental status
**[[Cerebral venous sinus thrombosis|Dural venous sinus thrombosis]]
* Glasgow coma scale is ___ / 15
**[[Meningitis]], [[encephalitis]], focal [[Neurology|neurological]] deficits, and [[psychiatric]] symptoms
* Clonus may be present
**Irreversible [[dementia]]
* 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===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
*[[Monoarthritis]] or [[polyarthritis]]  
OR
*[[Knee|Knees]] are the most commonly affected [[Joint|joints]], followed by [[Wrist|wrists]], [[Ankle|ankles]], and [[Elbow|elbows]]
*[[Clubbing]]  
*The [[arthritis]] is typically nonerosive
*[[Cyanosis]]  
 
*Pitting/non-pitting [[edema]] of the upper/lower extremities
===Gallery===
*Muscle atrophy
*Fasciculations in the upper/lower extremity


Monoarthritis or polyarthritis occurs in at least 50% of patients. Knees are the most commonly affected joints, followed by wrists, ankles, and elbows. The arthritis is typically nonerosive.
[[File:Behcet's syndrome 01.jpeg|200x200px|thumb|left|Oral ulcer [http://atlasdermatologico.com.br/disease.jsf?diseaseId=53 Source:Created by Samuel Freire da Silva, M.D. in homage to The Master And Professor Delso Bringel Calheiros]]]
<br clear="left" />


===Gallery===
[[File:Behcet's syndrome 03.jpeg|200x200px|thumb|left|Genital ulcer [http://atlasdermatologico.com.br/disease.jsf?diseaseId=53 Source:Created by Samuel Freire da Silva, M.D. in homage to The Master And Professor Delso Bringel Calheiros]]]
<br clear="left" />


====Oral cavity====
[[File:Behcet's syndrome 10.jpeg|200x200px|thumb|left|Penile ulcer [http://atlasdermatologico.com.br/disease.jsf?diseaseId=53 Source:Created by Samuel Freire da Silva, M.D. in homage to The Master And Professor Delso Bringel Calheiros]]]
<br clear="left" />


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==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Autoimmune diseases]]
 
[[Category:Medicine]]
[[Category:Up-To-date]]
[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:Rheumatology]]
[[Category:Rheumatology]]
[[Category:Needs content]]

Latest revision as of 20:36, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Jesus Rosario Hernandez, M.D. [3]

Overview

Patients with Behçet disease usually appear normal. Vital signs of patients with Behçet disease are usually normal. The presence of mouth sores, genital ulcers, and vision problems on physical examination are diagnostic of Behçet disease. Skin examination of patients with Behçet disease shows erythema nodosum lesions typically occur on the extremities, especially the lower legs, but they can also be observed on the face, neck, and buttocks. The lesions are painful and resolve spontaneously, although some may ulcerate or leave hyperpigmentation. A folliculitis like rash, resembling acne vulgaris, appears on the face, neck, chest, back, and hairline of patients. Some lesions become more pustular; 24-48 hours after a sterile needle prick, some patients develop erythema with a nodule or pustule at the prick site. Ophthalmoscopic exam may be abnormal with findings of retinal vasculitis, and vaso-occlusive lesions. Uveitis of anterior and posterior chambers diagnosed with slit-lamp examination. Erythematous throat with tonsillar swelling, and exudates. Ulcers 2-15 mm in diameter, with a necrotic center and surrounding red rim. A white or yellow pseudomembrane covers the surface of the ulcer. The ulcers are typically painful, nonscarring, and found on the lips, buccal mucosa, tongue, tonsils, and larynx. Most last 7-14 days and occur in crops. Hypopyon may be observed in the anterior chamber. Genitourinary examination of patients with Behçet disease will show ulcers on the scrotum and vulva, painful and heal with scarring. Genital ulcerations tend to be deeper and larger than the oral lesions. Females can have asymptomatic ulcers. Neuromuscular examination of patients with Behçet disease will show CNS involvement in 25% of the cases. Immune-mediated meningoencephalitis predominantly involves the brainstem. Meningitis, encephalitis, focal neurological deficits, and psychiatric symptoms can be present. Irreversible dementia can occur.

Physical Examination

Physical examination of patients with Behçet disease is usually remarkable for: skin lesions, genital lesions, and neuromuscular complications.[1][2][3]

Appearance of the Patient

  • Patients with Behçet disease usually appear normal.

Vital Signs

  • Vital signs of patients with Behçet disease are usually normal.

Skin

HEENT

Neck

  • Neck examination of patients with Behçet disease is usually normal.

Lungs

  • Pulmonary examination of patients with Behçet disease is usually normal.

Heart

  • Cardiovascular examination of patients with Behçet disease is usually normal.

Abdomen

  • Abdominal examination of patients with Behçet disease is usually normal.

Back

  • Back examination of patients with Behçet disease is usually normal.

Genitourinary

Neuromuscular

Extremities

Gallery

Oral ulcer Source:Created by Samuel Freire da Silva, M.D. in homage to The Master And Professor Delso Bringel Calheiros


Genital ulcer Source:Created by Samuel Freire da Silva, M.D. in homage to The Master And Professor Delso Bringel Calheiros


Penile ulcer Source:Created by Samuel Freire da Silva, M.D. in homage to The Master And Professor Delso Bringel Calheiros


Genital area

References

  1. ↑ Zouboulis CC, Vaiopoulos G, Marcomichelakis N, Palimeris G, Markidou I, Thouas B; et al. (2003). "Onset signs, clinical course, prognosis, treatment and outcome of adult patients with Adamantiades-Behçet's disease in Greece". Clin Exp Rheumatol. 21 (4 Suppl 30): S19–26. PMID 14727454.
  2. ↑ Moses Alder N, Fisher M, Yazici Y (2008). "Behçet's syndrome patients have high levels of functional disability, fatigue and pain as measured by a Multi-dimensional Health Assessment Questionnaire (MDHAQ)". Clin Exp Rheumatol. 26 (4 Suppl 50): S110–3. PMID 19026127.
  3. ↑ "Criteria for diagnosis of Behçet's disease. International Study Group for Behçet's Disease". Lancet. 335 (8697): 1078–80. 1990. PMID 1970380.
  4. ↑ Kural-Seyahi E, Fresko I, Seyahi N, Ozyazgan Y, Mat C, Hamuryudan V; et al. (2003). "The long-term mortality and morbidity of Behçet syndrome: a 2-decade outcome survey of 387 patients followed at a dedicated center". Medicine (Baltimore). 82 (1): 60–76. PMID 12544711.

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