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==Overview==
==Overview==
Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for [[muscle weakness]], [[hyporeflexia]], [[skin]] lesions, [[Respiratory system|respiratory]] symptoms. The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis. [[Muscle atrophy]] in severe, long standing disease might occur.


==Physical Examination==
==Physical Examination==
*Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for [[muscle weakness]], [[hyporeflexia]], [[skin]] lesions, [[Respiratory system|respiratory]] symptoms.<ref name="KhanChristopher-Stine2011">{{cite journal|last1=Khan|first1=Sabiha|last2=Christopher-Stine|first2=Lisa|title=Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features|journal=Rheumatic Disease Clinics of North America|volume=37|issue=2|year=2011|pages=143–158|issn=0889857X|doi=10.1016/j.rdc.2011.01.001}}</ref><ref name="DoblougGaren2015">{{cite journal|last1=Dobloug|first1=Cecilie|last2=Garen|first2=Torhild|last3=Bitter|first3=Helle|last4=Stjärne|first4=Johan|last5=Stenseth|first5=Guri|last6=Grøvle|first6=Lars|last7=Sem|first7=Marthe|last8=Gran|first8=Jan Tore|last9=Molberg|first9=Øyvind|title=Prevalence and clinical characteristics of adult polymyositis and dermatomyositis; data from a large and unselected Norwegian cohort|journal=Annals of the Rheumatic Diseases|volume=74|issue=8|year=2015|pages=1551–1556|issn=0003-4967|doi=10.1136/annrheumdis-2013-205127}}</ref><ref name="ChinoyFertig2007">{{cite journal|last1=Chinoy|first1=H.|last2=Fertig|first2=N.|last3=Oddis|first3=C. V|last4=Ollier|first4=W. E R|last5=Cooper|first5=R. G|title=The diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis|journal=Annals of the Rheumatic Diseases|volume=66|issue=10|year=2007|pages=1345–1349|issn=0003-4967|doi=10.1136/ard.2006.068502}}</ref><ref name="DalakasHohlfeld2003">{{cite journal|last1=Dalakas|first1=Marinos C|last2=Hohlfeld|first2=Reinhard|title=Polymyositis and dermatomyositis|journal=The Lancet|volume=362|issue=9388|year=2003|pages=971–982|issn=01406736|doi=10.1016/S0140-6736(03)14368-1}}</ref><ref name="DouglasTazelaar2001">{{cite journal|last1=Douglas|first1=William W.|last2=Tazelaar|first2=Henry D.|last3=Hartman|first3=Thomas E.|last4=Hartman|first4=Robert P.|last5=Decker|first5=Paul A.|last6=Schroeder|first6=Darrell R.|last7=Ryu|first7=Jay H.|title=Polymyositis–Dermatomyositis-associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=164|issue=7|year=2001|pages=1182–1185|issn=1073-449X|doi=10.1164/ajrccm.164.7.2103110}}</ref>
*The presence of gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis.
*The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis.
*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 polymyositis and dermatomyositis usually appear normal. They might be weak in severe cases.  


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


*High-grade / low-grade fever
*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 eruptions like:
*[[Skin]] manifestations of dermatomyositis are as follow:<ref name="KhanChristopher-Stine2011">{{cite journal|last1=Khan|first1=Sabiha|last2=Christopher-Stine|first2=Lisa|title=Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features|journal=Rheumatic Disease Clinics of North America|volume=37|issue=2|year=2011|pages=143–158|issn=0889857X|doi=10.1016/j.rdc.2011.01.001}}</ref>
**Gottron's papules is pathognomonic of dermatomyositis.
{| class="wikitable"
**Heliotrope eruption is pathognomonic of dermatomyositis.
!Lesion
**Gottron's sign  
!Location
**Facial erythema  
!Percentage
**Photodistributed poikiloderma
!Pathognomonic
**Nailfold changes
|-
**Scalp involvement
!Gottron papules
**Calcinosis cutis
|Dorsal aspect of [[interphalangeal]] or [[Metacarpophalangeal joint|metacarpophalangeal joints]]
**Mechanic's hands
|80%
**Cutaneous ulceration
|Pathognomonic
|-
!Heliotrope rash
|[[Eyelid|Eyelids]] and periorbital tissue  
|
|Pathognomonic
|-
!Gottron sign  
|Dorsal aspect of the [[interphalangeal]] or [[Metacarpophalangeal joint|metacarpophalangeal]] joints, [[Olecranon|olecranon process]], [[patella]], and medial malleoli  
|
|Characteristic
|-
![[Macule|Macular]] violaceous [[erythema]]  
|Symmetric distribution in classic areas  
|
|Characteristic
|-
!Shawl sign
|Nape of the [[neck]], [[Shoulder|shoulders]], and upper [[Human back|back]]
|
|Characteristic
|-
!“V sign”
|V-shaped region of the [[neck]] and upper [[chest]]  
|
|Characteristic
|-
!Linear extensor [[erythema]]  
|Extensor aspects of the [[Leg|legs]], [[Thigh|thighs]], [[Arm|arms]], [[Finger|fingers]], [[Hand|hands]], and [[Foot (length)|feet]]
|
|Characteristic
|-
!Mechanic’s hands  
|[[Hand|Palms]] and [[Finger|fingers]]  
|
|Characteristic
|-
![[Nail (anatomy)|Nail]] abnormalities such as
* Nailfold [[Telangiectasia|telangiectasias]]
* Cuticular overgrowth
* Prominent periungual [[erythema]]  
|[[Nail (anatomy)|Nail]] of [[Hand|hands]] and [[Foot (length)|feet]]
|30-60%
|Characteristic
|-
![[Calcinosis cutis|Cutaneous calcinosis]]
|Sites of compression, such as [[Elbow|elbows]] and [[buttocks]]
|30-70% in [[Juvenile dermatomyositis|JDM]]
 
10% in DM
|
|-
!Flagellate [[erythema]]  
|[[Trunk]], [[Human back|back]], and proximal [[Limb (anatomy)|extremities]]
|
|Rare
|-
![[Poikiloderma of civatte|Poikiloderma]]  
|Sun exposed areas
|
|Rare
|-
![[Pityriasis rubra pilaris]]–like lesions  
|dorsal aspect of the [[Hand|hands]] and [[Foot (length)|feet]], frequently over the bony prominences  
|
|Rare
|-
!Nonscarring [[alopecia]]
|[[Head]]
|
|Rare
|-
![[Erythroderma]]
|
|
|Rare
|-
!Vesiculobullous lesions
|
|
|Rare
|-
!Cutaneous [[vasculitis]] such as
* Palpable [[purpura]]
* [[Urticaria]]-like lesions
* [[Livedoid vasculitis|Livedo reticularis]]
* Digital [[Ulcer|ulcerations]]  
|
|
|Rare
|-
![[Hypersensitivity vasculitis|Leukocytoclastic vasculitis]]  
|Underlying [[Cancer|malignancy]]
|
|Rare
|-
![[Raynaud's phenomenon|Raynaud phenomenon]]  
|
|25%
|
|}


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* [[Periorbital edema]]
OR
* 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 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 polymyositis and dermatomyositis 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.
* Asymmetric [[Respiratory examination|chest expansion]]
OR
*Lungs are hyporesonant
* Asymmetric chest expansion / Decreased chest expansion
*Fine [[crackles]] upon auscultation of the lung bilaterally
*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
*[[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 polymyositis and dermatomyositis 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 polymyositis and dermatomyositis 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 polymyositis and dermatomyositis 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 polymyositis and dermatomyositis is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 
===Neuromuscular===
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
*Patient is usually oriented to persons, place, and time.
* Symmetric proximal muscle weakness mostly in:
* Symmetric proximal [[muscle weakness]] mostly in:
**Deltoids
**[[Deltoid|Deltoids]]
**Hips
**[[Hip (anatomy)|Hips]]
**Neck flexors
**[[Neck]] flexors
* Mild distal muscle weakness
* Mild distal [[muscle weakness]]


* Hyperreflexia / hyporeflexia / areflexia
* [[Hyporeflexia]] / [[Hyporeflexia|areflexia]]
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* [[Hypertonia|Muscle rigidity]]
* 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.
*[[Muscle atrophy]] in severe, long standing disease  
OR
*[[Fasciculation|Fasciculations]] in the upper/lower extremity
*[[Clubbing]]
*[[Cyanosis]]  
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy in severe, longstanding disease
*Fasciculations in the upper/lower extremity


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 13:20, 4 June 2018

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

Overview

Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for muscle weakness, hyporeflexia, skin lesions, respiratory symptoms. The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis. Muscle atrophy in severe, long standing disease might occur.

Physical Examination

  • Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for muscle weakness, hyporeflexia, skin lesions, respiratory symptoms.[1][2][3][4][5]
  • The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis.

Appearance of the Patient

  • Patients with polymyositis and dermatomyositis usually appear normal. They might be weak in severe cases.

Vital Signs

Skin

  • Skin manifestations of dermatomyositis are as follow:[1]
Lesion Location Percentage Pathognomonic
Gottron papules Dorsal aspect of interphalangeal or metacarpophalangeal joints 80% Pathognomonic
Heliotrope rash Eyelids and periorbital tissue   Pathognomonic
Gottron sign   Dorsal aspect of the interphalangeal or metacarpophalangeal joints, olecranon process, patella, and medial malleoli   Characteristic
Macular violaceous erythema   Symmetric distribution in classic areas   Characteristic
Shawl sign Nape of the neck, shoulders, and upper back Characteristic
“V sign” V-shaped region of the neck and upper chest   Characteristic
Linear extensor erythema   Extensor aspects of the legs, thighs, arms, fingers, hands, and feet Characteristic
Mechanic’s hands   Palms and fingers   Characteristic
Nail abnormalities such as Nail of hands and feet 30-60% Characteristic
Cutaneous calcinosis Sites of compression, such as elbows and buttocks 30-70% in JDM

10% in DM

Flagellate erythema   Trunk, back, and proximal extremities Rare
Poikiloderma   Sun exposed areas Rare
Pityriasis rubra pilaris–like lesions   dorsal aspect of the hands and feet, frequently over the bony prominences   Rare
Nonscarring alopecia Head Rare
Erythroderma Rare
Vesiculobullous lesions Rare
Cutaneous vasculitis such as Rare
Leukocytoclastic vasculitis   Underlying malignancy Rare
Raynaud phenomenon   25%

HEENT

Neck

  • Neck examination of patients with polymyositis and dermatomyositis is usually normal.

Lungs

Heart

  • Cardiovascular examination of patients with polymyositis and dermatomyositis is usually normal.

Abdomen

  • Abdominal examination of patients with polymyositis and dermatomyositis is usually normal.

Back

  • Back examination of patients with polymyositis and dermatomyositis is usually normal.

Genitourinary

  • Genitourinary examination of patients with polymyositis and dermatomyositis is usually normal.

Neuromuscular

Extremities

References

  1. ↑ 1.0 1.1 Khan, Sabiha; Christopher-Stine, Lisa (2011). "Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features". Rheumatic Disease Clinics of North America. 37 (2): 143–158. doi:10.1016/j.rdc.2011.01.001. ISSN 0889-857X.
  2. ↑ Dobloug, Cecilie; Garen, Torhild; Bitter, Helle; Stjärne, Johan; Stenseth, Guri; Grøvle, Lars; Sem, Marthe; Gran, Jan Tore; Molberg, Øyvind (2015). "Prevalence and clinical characteristics of adult polymyositis and dermatomyositis; data from a large and unselected Norwegian cohort". Annals of the Rheumatic Diseases. 74 (8): 1551–1556. doi:10.1136/annrheumdis-2013-205127. ISSN 0003-4967.
  3. ↑ Chinoy, H.; Fertig, N.; Oddis, C. V; Ollier, W. E R; Cooper, R. G (2007). "The diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis". Annals of the Rheumatic Diseases. 66 (10): 1345–1349. doi:10.1136/ard.2006.068502. ISSN 0003-4967.
  4. ↑ Dalakas, Marinos C; Hohlfeld, Reinhard (2003). "Polymyositis and dermatomyositis". The Lancet. 362 (9388): 971–982. doi:10.1016/S0140-6736(03)14368-1. ISSN 0140-6736.
  5. ↑ Douglas, William W.; Tazelaar, Henry D.; Hartman, Thomas E.; Hartman, Robert P.; Decker, Paul A.; Schroeder, Darrell R.; Ryu, Jay H. (2001). "Polymyositis–Dermatomyositis-associated Interstitial Lung Disease". American Journal of Respiratory and Critical Care Medicine. 164 (7): 1182–1185. doi:10.1164/ajrccm.164.7.2103110. ISSN 1073-449X.
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