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{{Rheumatic fever}} | {{Rheumatic fever}} | ||
{{CMG}}; {{AE}} [[Varun Kumar, M.B.B.S.]] | {{CMG}}; {{AE}} [[Varun Kumar, M.B.B.S.]] {{AG}} | ||
==Overview== | |||
Common physical examination findings of rheumatic fever include [[fever]], [[cardiac murmur]]s, and [[erythema marginatum]]. | |||
==Physical Examination== | ==Physical Examination== | ||
Common physical examination findings of rheumatic fever include:<ref name="pmid1518750">{{cite journal| author=Ayoub EM| title=Resurgence of rheumatic fever in the United States. The changing picture of a preventable illness. | journal=Postgrad Med | year= 1992 | volume= 92 | issue= 3 | pages= 133-6, 139-42 | pmid=1518750 | doi= | pmc= | url= }} </ref><ref name="pmid13249623">{{cite journal| author=BURKE JB| title=Erythema marginatum. | journal=Arch Dis Child | year= 1955 | volume= 30 | issue= 152 | pages= 359-65 | pmid=13249623 | doi= | pmc=PMC2011784 | url= }} </ref> | |||
*[[Fever]] | *[[Fever]] | ||
*[[Cardiac murmurs]] | *[[Cardiac murmurs]] | ||
*[[Erythema marginatum]] | |||
*[[Sydenham's chorea]] | *[[Sydenham's chorea]] | ||
*Migratory polyarthritis | *Migratory polyarthritis, often in large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints) | ||
*Subcutaneous nodules over extensor surface of limbs | *Subcutaneous nodules over extensor surface of limbs and bony prominences such as elbows, knees, ankles and knuckles | ||
===General appearance=== | ===General appearance=== | ||
High index of suspicion is required in diagnosing rheumatic fever. Patients | High index of suspicion is required in diagnosing rheumatic fever. Patients present frequently with joint involvement and fatigue. | ||
===Vital signs=== | ===Vital signs=== | ||
*[[Fever]] | *[[Fever]] | ||
*Normotension or [[Hypotension]] (if | *Normotension or [[Hypotension]] (if [[pericardium]] is involved) | ||
*[[Tachycardia]] | *[[Tachycardia]] | ||
*[[Tachypnea]] (if heart valves, pericardium or myocardium are involved leading to cardiac dysfunction) | *[[Tachypnea]] (if [[heart valves]], [[pericardium]] or [[myocardium]] are involved leading to cardiac dysfunction) | ||
===Cardiac examination=== | ===Cardiac examination=== | ||
Cardiac involvement is the second most common complication of rheumatic fever. | Cardiac involvement is the second most common complication of rheumatic fever. Signs include:<ref name="pmid4233112">{{cite journal| author=Dressler W| title=Precordial heave on the right related to left-atrial enlargement. | journal=JAMA | year= 1968 | volume= 205 | issue= 9 | pages= 642-3 | pmid=4233112 | doi= | pmc= | url= }} </ref> may be noted in chronic rheumatic disease with mitral valve involvement<ref name="pmid17786377">{{cite journal| author=Dray N, Balaguru D, Pauliks LB| title=Abnormal left ventricular longitudinal wall motion in rheumatic mitral stenosis before and after balloon valvuloplasty: a strain rate imaging study. | journal=Pediatr Cardiol | year= 2008 | volume= 29 | issue= 3 | pages= 663-6 | pmid=17786377 | doi=10.1007/s00246-007-9047-5 | pmc= | url= }} </ref><ref name="pmid1404745">{{cite journal| author=| title=Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. | journal=JAMA | year= 1992 | volume= 268 | issue= 15 | pages= 2069-73 | pmid=1404745 | doi= | pmc= | url= }} </ref><ref name="pmid12417554">{{cite journal| author=Ferrieri P, Jones Criteria Working Group| title=Proceedings of the Jones Criteria workshop. | journal=Circulation | year= 2002 | volume= 106 | issue= 19 | pages= 2521-3 | pmid=12417554 | doi= | pmc= | url= }} </ref> | ||
*[[Tachycardia]] | *[[Tachycardia]] | ||
*[[Jugular venous distension]], [[S3|S<sub>3</sub>]] or occasionally a [[summation gallop]] may be noted if the patient has [[congestive heart failure]] secondary to valvular or [[myocarditis|myocardial involvement]]. | *[[Jugular venous distension]], [[S3|S<sub>3</sub>]] or occasionally a [[summation gallop]] may be noted if the patient has [[congestive heart failure]] secondary to valvular or [[myocarditis|myocardial involvement]]. | ||
*[[ | *[[Parasternal heave]] | ||
*[[Cardiac murmurs]] | *[[Cardiac murmurs]] if heart valves are involved. Regurgitant murmurs are common in acute rheumatic fever, while chronic rheumatic fever is associated with murmurs of valve stenosis. Murmurs include: | ||
**[[Mitral insufficiency]] ([[holosystolic murmur]]) is the most | **[[Mitral insufficiency]] ([[holosystolic murmur]]) is the most commonly, usually accompanied by [[aortic insufficiency]] and ([[early diastolic murmur]]) | ||
**[[Aortic stenosis]] ([[systolic ejection murmur]]) or [[mitral stenosis]] ([[mid diastolic murmur]]) may be noted in chronic rheumatic fever | **[[Aortic stenosis]] ([[systolic ejection murmur]]) or [[mitral stenosis]] ([[mid diastolic murmur]]) may be noted in chronic rheumatic fever due to scarring and calcification of damaged valves | ||
*[[Pericardial friction rub]] and low intensity [[heart sounds]] may be evident if [[pericardium]] is involved causing [[pericarditis]] and [[pericardial | *[[Pericardial friction rub]] and low intensity [[heart sounds]] may be evident if [[pericardium]] is involved causing [[pericarditis]] and [[pericardial effusion]] | ||
===Respiratory examination=== | ===Respiratory examination=== | ||
Revision as of 19:47, 16 October 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. Anthony Gallo, B.S. [2]
Overview
Common physical examination findings of rheumatic fever include fever, cardiac murmurs, and erythema marginatum.
Physical Examination
Common physical examination findings of rheumatic fever include:[1][2]
- Fever
- Cardiac murmurs
- Erythema marginatum
- Sydenham's chorea
- Migratory polyarthritis, often in large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints)
- Subcutaneous nodules over extensor surface of limbs and bony prominences such as elbows, knees, ankles and knuckles
General appearance
High index of suspicion is required in diagnosing rheumatic fever. Patients present frequently with joint involvement and fatigue.
Vital signs
- Fever
- Normotension or Hypotension (if pericardium is involved)
- Tachycardia
- Tachypnea (if heart valves, pericardium or myocardium are involved leading to cardiac dysfunction)
Cardiac examination
Cardiac involvement is the second most common complication of rheumatic fever. Signs include:[3] may be noted in chronic rheumatic disease with mitral valve involvement[4][5][6]
- Tachycardia
- Jugular venous distension, S3 or occasionally a summation gallop may be noted if the patient has congestive heart failure secondary to valvular or myocardial involvement.
- Parasternal heave
- Cardiac murmurs if heart valves are involved. Regurgitant murmurs are common in acute rheumatic fever, while chronic rheumatic fever is associated with murmurs of valve stenosis. Murmurs include:
- Mitral insufficiency (holosystolic murmur) is the most commonly, usually accompanied by aortic insufficiency and (early diastolic murmur)
- Aortic stenosis (systolic ejection murmur) or mitral stenosis (mid diastolic murmur) may be noted in chronic rheumatic fever due to scarring and calcification of damaged valves
- Pericardial friction rub and low intensity heart sounds may be evident if pericardium is involved causing pericarditis and pericardial effusion
Respiratory examination
- Epistaxis may be present in rheumatic fever if associated with severe carditis.
- The lung fields may be dull on percussion in presence of infection or pleural effusion
- Basilar crackles may be heard on auscultation, which may be suggestive of pulmonary edema
- Decreased breath sounds may be noted in presence of an accompanying pleural effusion
Neurological examination
- Sydenham's chorea also known as St. Vitus' dance is a characteristic series of rapid movements of the face and arms without purpose and emotional disturbances[7]. This can occur very late in the disease for at least three months from onset of infection. Usually only one side of the body is involved and ceases during sleep.
{{#ev:youtube|RsIQFeYOkAg}}
- Hand writing samples may be used in assessing the progress or resolution of the condition.
- Spooning sign which is the flexion of the wrists and extension of the fingers when the hands are extended
- Pronator sign which is turning outwards of the arms and palms when held above the head
- Inability to maintain protrusion of the tongue.
- Milk maids' sign may be noted, which is an intermittent increase and decrease of hand grip pressure as demonstrated in the video below.
{{#ev:youtube|7ThLWc6gGWw}}
Abdominal examination
Ascites may be observed if heart failure and fluid overload is present.
Extremities
- Arthritis may be noted in 70-75% of patients. Often large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints) are involved progressing below-upwards. However, other small joints can also be affected[8]. Arthritis in rheumatic fever is know to be migratory in nature and affecting multiple joints, persisting at each site for approximately one week.
- Affected joints may be swollen, erythematous, warm and tender, limiting the normal range of movement.
- Subcutaneous nodules may be noted in approximately 10% of rheumatic fever patients. They are usually symmetric and appear on extensor surface of limbs, over bony prominences such as elbows, knees, ankles and knuckles[1]. These nodules are firm and non-tender without involvement of the overlying skin. These nodules are usually associated with severe carditis.
- Pedal edema may be observed if congestive heart failure and fluid overload are present.
Skin
Erythema marginatum, also known as erythema annulare are pink-red rash frequently located on trunk, limbs and seldom on face[2]. They appear as non-pruretic macules or papules extending centrifugally outwards with central clearing and raised outer margins. The rash may resolve and reappear within few hours and can be accentuated by heat in the form of hot shower.
References
- ↑ 1.0 1.1 Ayoub EM (1992). "Resurgence of rheumatic fever in the United States. The changing picture of a preventable illness". Postgrad Med. 92 (3): 133–6, 139–42. PMID 1518750.
- ↑ 2.0 2.1 BURKE JB (1955). "Erythema marginatum". Arch Dis Child. 30 (152): 359–65. PMC 2011784. PMID 13249623.
- ↑ Dressler W (1968). "Precordial heave on the right related to left-atrial enlargement". JAMA. 205 (9): 642–3. PMID 4233112.
- ↑ Dray N, Balaguru D, Pauliks LB (2008). "Abnormal left ventricular longitudinal wall motion in rheumatic mitral stenosis before and after balloon valvuloplasty: a strain rate imaging study". Pediatr Cardiol. 29 (3): 663–6. doi:10.1007/s00246-007-9047-5. PMID 17786377.
- ↑ "Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association". JAMA. 268 (15): 2069–73. 1992. PMID 1404745.
- ↑ Ferrieri P, Jones Criteria Working Group (2002). "Proceedings of the Jones Criteria workshop". Circulation. 106 (19): 2521–3. PMID 12417554.
- ↑ SACKS L, FEINSTEIN AR, TARANTA A (1962). "A controlled psychologic study of Sydenham's chorea". J Pediatr. 61: 714–22. PMID 13975949.
- ↑ Olgunturk R, Canter B, Tunaoglu FS, Kula S (2006). "Review of 609 patients with rheumatic fever in terms of revised and updated Jones criteria". Int J Cardiol. 112 (1): 91–8. doi:10.1016/j.ijcard.2005.11.007. PMID 16364469.