Granulomatosis with polyangiitis physical examination: Difference between revisions

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{{Wegener's granulomatosis}}
{{Wegener's granulomatosis}}
{{CMG}}{{APM}}{{AE}}{{KW}}
{{CMG}}{{APM}}{{AE}}{{ADS}}{{KW}}


==Overview==
==Overview==
A complete medical history and a comprehensive renal, pulmonary, and ENT examination must be preformed to help identify and properly diagnose Granulomatosis with polyangiitis from other diseases.
The important physical exam findings are [[Ulcerations]], palpable [[purpura]] and subcutaneous [[nodules]] in the skin; [[conjunctivitis]], [[uveitis]], [[sinusitis]], [[purulent]] exudate from nares,[[saddle nose]] deformity, reduced hearing in the head and neck; [[pleuritic chest pain]] ans signs of [[atelectasis]] in lung examination; and signs of [[mononeuritis multiplex]] on neural exam.


==Physical Examination==
==Physical Examination==
A complete medical history and a comprehensive renal, pulmonary, and ENT examination must be preformed to help identify and properly diagnose Granulomatosis with polyangiitis form other diseases. A thorough physical examination can provide insight into possible causes and associated underlying conditions. The following findings may be present during a physical examination of Granulomatosis with polyangiitis:
*Physical examination of patients with Granulomatosis with polyangiitis  is usually remarkable for:<ref name="pmid15210387">{{cite journal |vauthors=Seo P, Stone JH |title=The antineutrophil cytoplasmic antibody-associated vasculitides |journal=Am. J. Med. |volume=117 |issue=1 |pages=39–50 |date=July 2004 |pmid=15210387 |doi=10.1016/j.amjmed.2004.02.030 |url=}}</ref><ref name="pmid17106496">{{cite journal |vauthors=Graves N |title=Wegener granulomatosis |journal=Proc (Bayl Univ Med Cent) |volume=19 |issue=4 |pages=342–4 |date=October 2006 |pmid=17106496 |pmc=1618758 |doi= |url=}}</ref>
 
*
* Saddle nose deformity
* Atelectasis
* Pleural effusion
* Dyspnea
* Hemoptysis
* Pericardial rub
* Mononeuritis multiplex
* Cranial nerve paralysis
* Palpable purpura
* Subcutaneous nodules
* Ulcerations
==Physical Examination==
*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===
*Patients with [disease name] usually appear [general appearance].


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


*High-grade / low-grade fever
*They usually have normal vital signs until infected.
*[[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.
The skin findings are seen in 14% of patients:<ref name="pmid8089286">{{cite journal |vauthors=Daoud MS, Gibson LE, DeRemee RA, Specks U, el-Azhary RA, Su WP |title=Cutaneous Wegener's granulomatosis: clinical, histopathologic, and immunopathologic features of thirty patients |journal=J. Am. Acad. Dermatol. |volume=31 |issue=4 |pages=605–12 |date=October 1994 |pmid=8089286 |doi= |url=}}</ref>
OR
*[[Ulcerations]]  
*[[Cyanosis]]  
*Palpable [[purpura]]  
*[[Jaundice]]
*Subcutaneous [[nodules]]
* [[Pallor]]
* Bruises


===HEENT===
===HEENT===
* [[Sinusitis]]
* [[Saddle nose]] deformity
* [[Scleritis]]
* [[Scleritis]]
* [[Keratitis]]
* [[Keratitis]]
* [[Uveitis]]
* [[Uveitis]]
* [[Conjunctivitis]]  
* [[Conjunctivitis]]  
* Icteric sclera
* [[Proptosis]]
* [[Nystagmus]]  
* [[Xanthelasma]]  
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
* [[Purulent]] exudate from the nares
*Ophthalmoscopic exam may be abnormal with findings of ___
* [[Sinusitis]]<ref name="pmid19263410">{{cite journal |vauthors=Cannady SB, Batra PS, Koening C, Lorenz RR, Citardi MJ, Langford C, Hoffman GS |title=Sinonasal Wegener granulomatosis: a single-institution experience with 120 cases |journal=Laryngoscope |volume=119 |issue=4 |pages=757–61 |date=April 2009 |pmid=19263410 |doi=10.1002/lary.20161 |url=}}</ref>
* Hearing acuity may be reduced
* [[Saddle nose]] deformity
*[[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".)
* [[Otitis Media]]
*[[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".)
* Hearing acuity may be reduced<ref name="pmid15210387" />
* [[Exudate]] from the ear canal
*[[Weber test]] may be abnormal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*[[Rinne test]] may be positive  
*Inflamed nares / congested nares
*[[Gingival hyperplasia]] or necrotizing [[gingivitis]]<ref name="pmid251963202">{{cite journal |vauthors=Genuis K, Pewarchuk J |title=Granulomatosis with polyangiitis (Wegener's) as a necrotizing gingivitis mimic: a case report |journal=J Med Case Rep |volume=8 |issue= |pages=297 |date=September 2014 |pmid=25196320 |pmc=4168997 |doi=10.1186/1752-1947-8-297 |url=}}</ref> can be seen
* [[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 granulomatosis with polyangiitis 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.
Examination may show signs of:
OR
*[[Pleuritic pain]]
* Asymmetric chest expansion / Decreased chest expansion
*[[Atelectasis physical examination|Atelectasis]]
*Lungs are hypo/hyperresonant
* [[Pleural effusion physical examination|Pleural effusion]]
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
* [[Pulmonary hypertension physical examination|Pulmonary hypertension]]- bibasilar crackles
*Rhonchi
* [[Subglottic stenosis]]
*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.
*[[Friction rub]]/ [[Pericardial friction rub|Pericardial rub]]
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#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#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 tenderness]] may be present<ref name="pmid15758841">{{cite journal |vauthors=Pagnoux C, Mahr A, Cohen P, Guillevin L |title=Presentation and outcome of gastrointestinal involvement in systemic necrotizing vasculitides: analysis of 62 patients with polyarteritis nodosa, microscopic polyangiitis, Wegener granulomatosis, Churg-Strauss syndrome, or rheumatoid arthritis-associated vasculitis |journal=Medicine (Baltimore) |volume=84 |issue=2 |pages=115–28 |date=March 2005 |pmid=15758841 |doi= |url=}}</ref>
 
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
*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 granulomatosis with polyangiitis 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.
OR
*A pelvic/adnexal mass may be palpated
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
OR
*Patient is usually oriented to persons, place, and time
*Patient is usually oriented to persons, place, and time
* Altered mental status
*[[Mononeuritis multiplex]]<ref name="pmid28273992">{{cite journal |vauthors=Anadure R, Narayanan C, Varadraj G, Nandeesh B |title=ANCA Associated Mononeuritis Multiplex with Overlap in Vasculitic Syndromes |journal=J Clin Diagn Res |volume=11 |issue=1 |pages=OD01–OD03 |date=January 2017 |pmid=28273992 |pmc=5324437 |doi=10.7860/JCDR/2017/22252.9149 |url=}}</ref>- Loss of sensory and motor functions
* Glasgow coma scale is ___ / 15
*Cranial nerve paralysis
* 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)
 
===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
* Extremities examination of patients with granulomatosis with polyangiitis is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 17:42, 11 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Ali Poyan Mehr, M.D. [2]Associate Editor(s)-in-Chief: Amandeep Singh M.D.[3]Krzysztof Wierzbicki M.D. [4]

Overview

The important physical exam findings are Ulcerations, palpable purpura and subcutaneous nodules in the skin; conjunctivitis, uveitis, sinusitis, purulent exudate from nares,saddle nose deformity, reduced hearing in the head and neck; pleuritic chest pain ans signs of atelectasis in lung examination; and signs of mononeuritis multiplex on neural exam.

Physical Examination

  • Physical examination of patients with Granulomatosis with polyangiitis is usually remarkable for:[1][2]

Vital Signs

  • They usually have normal vital signs until infected.

Skin

The skin findings are seen in 14% of patients:[3]

HEENT

Neck

  • Neck examination of patients with granulomatosis with polyangiitis is usually normal.

Lungs

Examination may show signs of:

Heart

Abdomen

Back

  • Back examination of patients with granulomatosis with polyangiitis is usually normal.

Genitourinary

  • A pelvic/adnexal mass may be palpated
  • Inflamed mucosa

Neuromuscular

  • Patient is usually oriented to persons, place, and time
  • Mononeuritis multiplex[7]- Loss of sensory and motor functions
  • Cranial nerve paralysis

Extremities

  • Extremities examination of patients with granulomatosis with polyangiitis is usually normal.

References

  1. ↑ 1.0 1.1 Seo P, Stone JH (July 2004). "The antineutrophil cytoplasmic antibody-associated vasculitides". Am. J. Med. 117 (1): 39–50. doi:10.1016/j.amjmed.2004.02.030. PMID 15210387.
  2. ↑ Graves N (October 2006). "Wegener granulomatosis". Proc (Bayl Univ Med Cent). 19 (4): 342–4. PMC 1618758. PMID 17106496.
  3. ↑ Daoud MS, Gibson LE, DeRemee RA, Specks U, el-Azhary RA, Su WP (October 1994). "Cutaneous Wegener's granulomatosis: clinical, histopathologic, and immunopathologic features of thirty patients". J. Am. Acad. Dermatol. 31 (4): 605–12. PMID 8089286.
  4. ↑ Cannady SB, Batra PS, Koening C, Lorenz RR, Citardi MJ, Langford C, Hoffman GS (April 2009). "Sinonasal Wegener granulomatosis: a single-institution experience with 120 cases". Laryngoscope. 119 (4): 757–61. doi:10.1002/lary.20161. PMID 19263410.
  5. ↑ Genuis K, Pewarchuk J (September 2014). "Granulomatosis with polyangiitis (Wegener's) as a necrotizing gingivitis mimic: a case report". J Med Case Rep. 8: 297. doi:10.1186/1752-1947-8-297. PMC 4168997. PMID 25196320.
  6. ↑ Pagnoux C, Mahr A, Cohen P, Guillevin L (March 2005). "Presentation and outcome of gastrointestinal involvement in systemic necrotizing vasculitides: analysis of 62 patients with polyarteritis nodosa, microscopic polyangiitis, Wegener granulomatosis, Churg-Strauss syndrome, or rheumatoid arthritis-associated vasculitis". Medicine (Baltimore). 84 (2): 115–28. PMID 15758841.
  7. ↑ Anadure R, Narayanan C, Varadraj G, Nandeesh B (January 2017). "ANCA Associated Mononeuritis Multiplex with Overlap in Vasculitic Syndromes". J Clin Diagn Res. 11 (1): OD01–OD03. doi:10.7860/JCDR/2017/22252.9149. PMC 5324437. PMID 28273992.
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