Cavernous sinus thrombosis physical examination: Difference between revisions

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==Physical Examination==
==Physical Examination==


Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Physical examination of patients with cavernous sinus thrombosis is usually remarkable for high fever, altered mental status, unilateral or bilateral [[exophthalmos]], periorbital edema (initially unilateral but typically bilateral), lid erythema, chemosis, ptosis, proptosis (due to impaired venous drainage of orbit), restricted or painful eye movement, and less commonly papilledema, retinal hemorrhages, decreased visual acuity, photophobia, diminished pupillary reflex, and pulsating conjunctiva.
 
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].


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with cavernous sinus thrombosis usually appear very ill and toxic.  


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


*High-grade / low-grade fever
*High-grade fever
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Low blood pressure with normal pulse pressure
*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.
OR
*[[Cyanosis]]  
*[[Cyanosis]]  
*[[Jaundice]]
*[[Jaundice]]
Line 41: Line 27:


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.<gallery widths="150px">
* Periorbital edema (initially unilateral but typically bilateral)
 
* Unilateral or bilateral [[exophthalmos]]
UploadedImage-01.jpg | Description {{dermref}}
* Extra-ocular movements may be abnormal from third, fourth and sixth cranial neuropathy
UploadedImage-02.jpg | Description {{dermref}}
** Sixth cranial neuropathy is the most common neuropathy (resulting in partial ophthalmoplegia with limited eye abduction).
 
*Pupils non-reactive to neither light nor accommodation (from paralysis of the iris and ciliary body)
</gallery>
*Lid erythema
OR
*Horner syndrome (ptosis, miosis, and anhidrosis)
* Abnormalities of the head/hair may include ___
*Chemosis
* Evidence of trauma
*Ptosis
* Icteric sclera
*Proptosis (due to impaired venous drainage of orbit)
* [[Nystagmus]]  
*Painful eye movement
* Extra-ocular movements may be abnormal
*Papilledema
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Retinal hemorrhages
*Ophthalmoscopic exam may be abnormal with findings of ___
*Decreased visual acuity
* Hearing acuity may be reduced
*Photophobia
*[[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".)
*Pulsating conjunctiva
*[[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
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
* Impaired corneal reflex.
* Blindness


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
*Stiff neck may be present.
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 cavernous sinus thrombosis is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR 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 cavernous sinus thrombosis 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 cavernous sinus thrombosis 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 cavernous sinus thrombosis 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 cavernous sinus thrombosis 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.
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Altered mental status
* Glasgow coma scale is ___ / 15
* Extra-ocular movements may be abnormal from third, fourth and sixth cranial neuropathy
* Clonus may be present
** Sixth cranial neuropathy is the most common neuropathy (resulting in partial ophthalmoplegia with limited eye abduction).
* Hyperreflexia / hyporeflexia / areflexia
* Photophobia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Horner syndrome (ptosis, miosis, and anhidrosis)
* Muscle rigidity
* Hyperreflexia
* Proximal/distal muscle weakness unilaterally/bilaterally
* Generalised weakness
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Abnormal gait
*Unilateral/bilateral upper/lower extremity weakness
*Decreased visual acuity
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Downgoing plantar reflex
*Positive straight leg raise test
*Ptosis
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Hemiparesis
*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 cavernous sinus thrombosis 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}}

Revision as of 14:44, 5 July 2018

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

Overview

Physical Examination

Physical examination of patients with cavernous sinus thrombosis is usually remarkable for high fever, altered mental status, unilateral or bilateral exophthalmos, periorbital edema (initially unilateral but typically bilateral), lid erythema, chemosis, ptosis, proptosis (due to impaired venous drainage of orbit), restricted or painful eye movement, and less commonly papilledema, retinal hemorrhages, decreased visual acuity, photophobia, diminished pupillary reflex, and pulsating conjunctiva.

Appearance of the Patient

  • Patients with cavernous sinus thrombosis usually appear very ill and toxic.

Vital Signs

  • High-grade fever
  • Tachycardia with regular pulse
  • Tachypnea
  • Low blood pressure with normal pulse pressure

Skin

HEENT

  • Periorbital edema (initially unilateral but typically bilateral)
  • Unilateral or bilateral exophthalmos
  • Extra-ocular movements may be abnormal from third, fourth and sixth cranial neuropathy
    • Sixth cranial neuropathy is the most common neuropathy (resulting in partial ophthalmoplegia with limited eye abduction).
  • Pupils non-reactive to neither light nor accommodation (from paralysis of the iris and ciliary body)
  • Lid erythema
  • Horner syndrome (ptosis, miosis, and anhidrosis)
  • Chemosis
  • Ptosis
  • Proptosis (due to impaired venous drainage of orbit)
  • Painful eye movement
  • Papilledema
  • Retinal hemorrhages
  • Decreased visual acuity
  • Photophobia
  • Pulsating conjunctiva
  • Facial tenderness
  • Impaired corneal reflex.
  • Blindness

Neck

  • Stiff neck may be present.

Lungs

  • Pulmonary examination of patients with cavernous sinus thrombosis is usually normal.

Heart

  • Cardiovascular examination of patients with cavernous sinus thrombosis is usually normal.

Abdomen

  • Abdominal examination of patients with cavernous sinus thrombosis is usually normal.

Back

  • Back examination of patients with cavernous sinus thrombosis is usually normal.

Genitourinary

  • Genitourinary examination of patients with cavernous sinus thrombosis is usually normal.

Neuromuscular

  • Altered mental status
  • Extra-ocular movements may be abnormal from third, fourth and sixth cranial neuropathy
    • Sixth cranial neuropathy is the most common neuropathy (resulting in partial ophthalmoplegia with limited eye abduction).
  • Photophobia
  • Horner syndrome (ptosis, miosis, and anhidrosis)
  • Hyperreflexia
  • Generalised weakness
  • Abnormal gait
  • Decreased visual acuity
  • Downgoing plantar reflex
  • Ptosis
  • Hemiparesis

Extremities

  • Extremities examination of patients with cavernous sinus thrombosis is usually normal.

References

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