Lead poisoning physical examination: Difference between revisions

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{{Lead poisoning}}
{{Lead poisoning}}


{{CMG}}; {{AE}} Aksiniya K. Stevasarova, MD
{{CMG}}; {{AE}}{{AKS}}


==Overview==
==Overview==
Patients with chronic [[lead poisoning]] usually appear very sick. Physical examination of patients with [[lead poisoning]] is usually remarkable for [[neurological]], [[gastrointestinal]], and [[hematological] problems.
Patients with chronic [[lead poisoning]] usually appear very sick. Physical examination of patients with [[lead poisoning]] is usually remarkable for [[neurological]]<ref name="pmid22269775">{{cite journal| author=Strayhorn JC, Strayhorn JM| title=Lead exposure and the 2010 achievement test scores of children in New York counties. | journal=Child Adolesc Psychiatry Ment Health | year= 2012 | volume= 6 | issue= 1 | pages= 4 | pmid=22269775 | doi=10.1186/1753-2000-6-4 | pmc=3292821 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22269775  }} </ref>, [[gastrointestinal]]<ref name="pmid28318192">{{cite journal| author=Mottier DM, Cargnel E| title=[Abdominal pain as a presentation by lead poisoning. Case report]. | journal=Arch Argent Pediatr | year= 2017 | volume= 115 | issue= 2 | pages= e96-e98 | pmid=28318192 | doi=10.5546/aap.2017.e96 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28318192  }} </ref>, and [[hematological]] problems.<ref name="pmid29651203">{{cite journal| author=Sachdeva C, Thakur K, Sharma A, Sharma KK| title=Lead: Tiny but Mighty Poison. | journal=Indian J Clin Biochem | year= 2018 | volume= 33 | issue= 2 | pages= 132-146 | pmid=29651203 | doi=10.1007/s12291-017-0680-3 | pmc=5891462 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29651203  }} </ref>


==Physical Examination==
==Physical Examination==
Line 17: Line 17:


* [[Learning disability]]
* [[Learning disability]]


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with [[lead poisoning]] usually appear normal.


===Vital Signs===
===Vital Signs===
 
*[[Tachycardia]] with regular pulse might be present due to anemia
*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 [[lead poisoning]] is usually normal.
OR
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises
 
<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.
* Abnormalities of the head may include: <ref name="pmid29651203">{{cite journal| author=Sachdeva C, Thakur K, Sharma A, Sharma KK| title=Lead: Tiny but Mighty Poison. | journal=Indian J Clin Biochem | year= 2018 | volume= 33 | issue= 2 | pages= 132-146 | pmid=29651203 | doi=10.1007/s12291-017-0680-3 | pmc=5891462 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29651203  }} </ref><ref name="pmid29523605">{{cite journal| author=Talbot A, Lippiatt C, Tantry A| title=Lead in a case of encephalopathy. | journal=BMJ Case Rep | year= 2018 | volume= 2018 | issue=  | pages=  | pmid=29523605 | doi=10.1136/bcr-2017-222388 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29523605  }} </ref>
OR
*[[Burton's lines]]<ref name="pmid16707743">{{cite journal| author=Nogué S, Culla A| title=Images in clinical medicine. Burton's line. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 20 | pages= e21 | pmid=16707743 | doi=10.1056/NEJMicm050064 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16707743  }} </ref>
* Abnormalities of the head/hair may include ___
*[[Icteric sclera]]
* Evidence of trauma
*[[Headache]]
* Icteric sclera
*[[Metallic taste]]
* [[Nystagmus]]  
*[[Irritability]]
* Extra-ocular movements may be abnormal
*[[Insomnia]]
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*[[excess lethargy]]
*Ophthalmoscopic exam may be abnormal with findings of ___
*[[hyperactivity]]
* Hearing acuity may be reduced
*[[seizure]]  
*[[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".)
*[[coma]]
*[[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".)
*[[learning disability]]<ref name="pmid22269775">{{cite journal| author=Strayhorn JC, Strayhorn JM| title=Lead exposure and the 2010 achievement test scores of children in New York counties. | journal=Child Adolesc Psychiatry Ment Health | year= 2012 | volume= 6 | issue= 1 | pages= 4 | pmid=22269775 | doi=10.1186/1753-2000-6-4 | pmc=3292821 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22269775  }} </ref>
* [[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 [[lead poisoning]] 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 [[lead poisoning]] 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.
* Cardiovascular examination of patients with [[lead poisoning]] might experience [[chest pain]].
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 [[lead poisoning]] might reveal<ref name="pmid29651203">{{cite journal| author=Sachdeva C, Thakur K, Sharma A, Sharma KK| title=Lead: Tiny but Mighty Poison. | journal=Indian J Clin Biochem | year= 2018 | volume= 33 | issue= 2 | pages= 132-146 | pmid=29651203 | doi=10.1007/s12291-017-0680-3 | pmc=5891462 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29651203  }} </ref>:
 
* [[Abdominal pain]]
OR
* [[Nausea]]
*[[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 examination of patients with [disease name] is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* 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)
 
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
 
 
The symptoms of chronic lead poisoning include neurological problems, such as
reduced cognitive abilities
 
*[[Nausea]]
 
*[[Abdominal pain]]
 
*[[Irritability]]
 
*[[Insomnia]]
 
*[[Mettalic taste]]
 
*excess [[lethargy]]
 
*[[Hyperactivity]]
 
*[[Chest pain]]
 
* [[headache]]
 
* [[seizure]]
 
* [[coma]]
 
There are also associated gastrointestinal problems, such as
 
* [[constipation]]
* [[constipation]]
* [[diarrhea]]
* [[diarrhea]]
* [[vomiting]]
* [[vomiting]]
* [[poor appetite]]
* [[poor appetite]]
* [[weight loss]]
* [[weight loss]]


Other associated effects are
===Back===
* Back examination of patients with [[lead poisoning]] is usually normal.


* [[anemia]]
===Genitourinary===
* Genitourinary examination of patients with [[lead poisoning]] might show:
*[[Acute nephropathy]] - manifests with tubular defects, including [[phosphaturia]], [[glucosuria]] and [[amino aciduria]]. This combination of tubular defects is referred as [[Fanconi’s syndrome]].
*[[Chronic nephropathy]] - characterized histologically with chronic interstitial nephritis and is associated with [[gout]] and [[hypertension]].


* kidney problems
===Neuromuscular===
* Neuromuscular examination of patients with [[lead poisoning]] might manifest with the following:<ref name="pmid29523605">{{cite journal| author=Talbot A, Lippiatt C, Tantry A| title=Lead in a case of encephalopathy. | journal=BMJ Case Rep | year= 2018 | volume= 2018 | issue=  | pages=  | pmid=29523605 | doi=10.1136/bcr-2017-222388 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29523605  }} </ref> <ref name="pmid29078718">{{cite journal| author=Ying XL, Gao ZY, Yan J, Zhang M, Wang J, Xu J et al.| title=Sources, symptoms and characteristics of childhood lead poisoning: experience from a lead specialty clinic in China. | journal=Clin Toxicol (Phila) | year= 2018 | volume= 56 | issue= 6 | pages= 397-403 | pmid=29078718 | doi=10.1080/15563650.2017.1391392 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29078718  }} </ref>
* Patient is usually oriented to persons, place, and time
* [[Delirium]]
* [[Hallucinations]]
* Weakness of extensor muscles (eg, [[foot drop]], [[wrist drop]])
* [[Hypersomnolent]] or have difficulty falling asleep
* [[ataxia]]
* [[aggressiveness]]
* [[attention difficulty]]


* reproductive problems
===Extremities===
 
*[[Foot drop]]  
===Physical examination===
*[[Wrist drop]]  
 
*[[Peripheral neuropathy]]
* [[Burton's line]]
 
* [[Peripheral neuropathy]]
 
* [[Wrist drop]]
 
* [[learning disability]]
 
===Laboratory tests===
 
* Basophilic stippling of red blood cells
 
* [[Iron deficiency anemia]] (microcytosis and hypochromia)
 
* Elevated serum lead levels
 
* K-fluorescent X-ray metering can measure bone-lead.


Shown below is an image depicting basophilic stippling in a blood smear of a patient with lead poisoning.<br>
=
[[File:Lead poisoning - blood film.jpg|Basophilic stippling in a blood smear of a patient with lead poisoning]]


==References==
==References==

Latest revision as of 20:55, 21 June 2018

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

Overview

Patients with chronic lead poisoning usually appear very sick. Physical examination of patients with lead poisoning is usually remarkable for neurological[1], gastrointestinal[2], and hematological problems.[3]

Physical Examination

  • Physical examination of patients with lead poisoning is usually remarkable for:

Appearance of the Patient

Vital Signs

  • Tachycardia with regular pulse might be present due to anemia

Skin

HEENT

Neck

Lungs

  • Pulmonary examination of patients with lead poisoning is usually normal.

Heart

Abdomen

Abdominal examination of patients with lead poisoning might reveal[3]:

Back

Genitourinary

Neuromuscular

Extremities

=

References

  1. ↑ 1.0 1.1 Strayhorn JC, Strayhorn JM (2012). "Lead exposure and the 2010 achievement test scores of children in New York counties". Child Adolesc Psychiatry Ment Health. 6 (1): 4. doi:10.1186/1753-2000-6-4. PMC 3292821. PMID 22269775.
  2. ↑ Mottier DM, Cargnel E (2017). "[Abdominal pain as a presentation by lead poisoning. Case report]". Arch Argent Pediatr. 115 (2): e96–e98. doi:10.5546/aap.2017.e96. PMID 28318192.
  3. ↑ 3.0 3.1 3.2 Sachdeva C, Thakur K, Sharma A, Sharma KK (2018). "Lead: Tiny but Mighty Poison". Indian J Clin Biochem. 33 (2): 132–146. doi:10.1007/s12291-017-0680-3. PMC 5891462. PMID 29651203.
  4. ↑ 4.0 4.1 Talbot A, Lippiatt C, Tantry A (2018). "Lead in a case of encephalopathy". BMJ Case Rep. 2018. doi:10.1136/bcr-2017-222388. PMID 29523605.
  5. ↑ Nogué S, Culla A (2006). "Images in clinical medicine. Burton's line". N Engl J Med. 354 (20): e21. doi:10.1056/NEJMicm050064. PMID 16707743.
  6. ↑ Ying XL, Gao ZY, Yan J, Zhang M, Wang J, Xu J; et al. (2018). "Sources, symptoms and characteristics of childhood lead poisoning: experience from a lead specialty clinic in China". Clin Toxicol (Phila). 56 (6): 397–403. doi:10.1080/15563650.2017.1391392. PMID 29078718.

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