Multiple sclerosis physical examination: Difference between revisions
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==Physical Examination== | ==Physical Examination== | ||
Physical examination of patients with | Physical examination of patients with multiple sclerosis is usually remarkable for: | ||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
* | *Gait and balance disturbance: Involvement of [[cerebellar]] tracts can cause [[Gait]] and balance problems in multiple sclerotic patients.<ref name="pmid25573524">{{cite journal |vauthors=Rinker JR, Salter AR, Walker H, Amara A, Meador W, Cutter GR |title=Prevalence and characteristics of tremor in the NARCOMS multiple sclerosis registry: a cross-sectional survey |journal=BMJ Open |volume=5 |issue=1 |pages=e006714 |date=January 2015 |pmid=25573524 |pmc=4289717 |doi=10.1136/bmjopen-2014-006714 |url=}}</ref> | ||
===Vital Signs=== | ===Vital Signs=== | ||
| Line 52: | Line 40: | ||
===HEENT=== | ===HEENT=== | ||
* | * Internuclear Ophthalmoplegia: [[Internuclear ophthalmoplegia]] ([[Internuclear ophthalmoplegia|INO]]) is defined as a gaze problem. Lesions in [[medial longitudinal fasciculus]] in [[brain stem]] are known to be the cause of [[Internuclear ophthalmoplegia|INO]].<ref name="pmid11552000">{{cite journal |vauthors=Frohman EM, Zhang H, Kramer PD, Fleckenstein J, Hawker K, Racke MK, Frohman TC |title=MRI characteristics of the MLF in MS patients with chronic internuclear ophthalmoparesis |journal=Neurology |volume=57 |issue=5 |pages=762–8 |date=September 2001 |pmid=11552000 |doi= |url=}}</ref> The signs of [[Internuclear ophthalmoplegia|INO]] are difficulty with [[Adduction|adducting]] in lateral gaze. For compensation of these problems, the contra lateral eye will have [[nystagmus]] leading to [[diplopia]]<ref name="pmid18678831">{{cite journal |vauthors=Mills DA, Frohman TC, Davis SL, Salter AR, McClure S, Beatty I, Shah A, Galetta S, Eggenberger E, Zee DS, Frohman EM |title=Break in binocular fusion during head turning in MS patients with INO |journal=Neurology |volume=71 |issue=6 |pages=458–60 |date=August 2008 |pmid=18678831 |doi=10.1212/01.wnl.0000324423.08538.dd |url=}}</ref> or [[vertigo]].<ref name="pmid15136670">{{cite journal |vauthors=Kim JS |title=Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction |journal=Neurology |volume=62 |issue=9 |pages=1491–6 |date=May 2004 |pmid=15136670 |doi= |url=}}</ref> | ||
* Optic Neuritis: [[Optic neuritis]] can be the first [[Medical sign|sign]] of multiple sclerosis, especially when it’s accompanied by [[white matter]] [[MRI]] [[lesions]].<ref>{{cite journal |author=Beck RW, Trobe JD |title=What we have learned from the Optic Neuritis Treatment Trial|journal=Ophthalmology |volume=102 |issue=10 |pages=1504-8 |year=1995 |pmid=9097798}}</ref><ref>{{cite journal |author= |title=The 5-year risk of MS after optic neuritis: experience of the optic neuritis treatment trial. 1997 |journal=Neurology |volume=57|issue=12 Suppl 5 |pages=S36-45 |year=2001 |pmid=11902594}}</ref> | |||
* Abnormalities of the head/hair may include ___ | * Abnormalities of the head/hair may include ___ | ||
* Evidence of trauma | * Evidence of trauma | ||
| Line 135: | Line 125: | ||
===Neuromuscular=== | ===Neuromuscular=== | ||
* | * Lhermitte's Sign: About 25-40% of MS patients experience [[lhermitte’s sign]] as an electrical shock sensation going downward from neck when the patients neck bends forward. [[Lhermitte's sign]] can correlate with [[MRI]] abnormalities of caudal [[medulla]] or cervical dorsal columns. .<ref>{{cite journal |author=Gutrecht JA, Zamani AA, Slagado ED|title=Anatomic-radiologic basis of Lhermitte's sign in multiple sclerosis |journal=Arch. Neurol. |volume=50 |issue=8 |pages=849-51|year=1993 |pmid=8352672 |doi=}}</ref><ref>{{cite journal |author=Al-Araji AH, Oger J |title=Reappraisal of Lhermitte's sign in multiple sclerosis |journal=Mult. Scler.|volume=11 |issue=4 |pages=398-402 |year=2005 |pmid=16042221 |doi=}}</ref><ref>{{cite journal |author=Sandyk R, Dann LC|title=Resolution of Lhermitte's sign in multiple sclerosis by treatment with weak electromagnetic fields |journal=Int. J. Neurosci.|volume=81 |issue=3-4 |pages=215-24 |year=1995 |pmid=7628912 |doi=}}</ref><ref>{{cite journal |author=Kanchandani R, Howe JG|title=Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature |journal=J. Neurol. Neurosurg. Psychiatr. |volume=45 |issue=4 |pages=308-12 |year=1982 |pmid=7077340 |doi=}}</ref> | ||
* Spasticity and increased reflexes: Damage to the [[upper motor neurons]] and decrease inhibition of [[lower motor neurons]] in [[MS]] can increase [[muscle tone]] and rigidity in 75% of [[MS]] patients.<ref name="pmid17868019">{{cite journal |vauthors=Boissy AR, Cohen JA |title=Multiple sclerosis symptom management |journal=Expert Rev Neurother |volume=7 |issue=9 |pages=1213–22 |date=September 2007 |pmid=17868019 |doi=10.1586/14737175.7.9.1213 |url=}}</ref> | |||
*Patient is usually oriented to persons, place, and | |||
*Patient is usually oriented to persons, place, and timet | |||
* Hyperreflexia / hyporeflexia / areflexia | * Hyperreflexia / hyporeflexia / areflexia | ||
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally | * Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally | ||
| Line 166: | Line 154: | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Revision as of 17:28, 15 February 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.
Overview
Physical examination of patients with multiple sclerosis is usually remarkable for lhermitte's sign, spasticity, increased reflexes, internuclear ophthalmoplegia, optic neuritis, and gait disturbance.
Physical Examination
Physical examination of patients with multiple sclerosis is usually remarkable for:
Appearance of the Patient
- Gait and balance disturbance: Involvement of cerebellar tracts can cause Gait and balance problems in multiple sclerotic patients.[1]
Vital Signs
- 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 examination of patients with [disease name] is usually normal.
OR
-
Description (Adapted from Dermatology Atlas)
-
Description (Adapted from Dermatology Atlas)
HEENT
- Internuclear Ophthalmoplegia: Internuclear ophthalmoplegia (INO) is defined as a gaze problem. Lesions in medial longitudinal fasciculus in brain stem are known to be the cause of INO.[2] The signs of INO are difficulty with adducting in lateral gaze. For compensation of these problems, the contra lateral eye will have nystagmus leading to diplopia[3] or vertigo.[4]
- Optic Neuritis: Optic neuritis can be the first sign of multiple sclerosis, especially when it’s accompanied by white matter MRI lesions.[5][6]
- 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 examination of patients with [disease name] 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
- Pulmonary examination of patients with [disease name] 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
- Cardiovascular examination of patients with [disease name] 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
- S1
- S2
- S3
- S4
- 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 stethoscope
Abdomen
- Abdominal examination of patients with [disease name] is usually normal.
OR
- Abdominal distension
- 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
- Lhermitte's Sign: About 25-40% of MS patients experience lhermitte’s sign as an electrical shock sensation going downward from neck when the patients neck bends forward. Lhermitte's sign can correlate with MRI abnormalities of caudal medulla or cervical dorsal columns. .[7][8][9][10]
- Spasticity and increased reflexes: Damage to the upper motor neurons and decrease inhibition of lower motor neurons in MS can increase muscle tone and rigidity in 75% of MS patients.[11]
- Patient is usually oriented to persons, place, and timet
- 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
References
- ↑ Rinker JR, Salter AR, Walker H, Amara A, Meador W, Cutter GR (January 2015). "Prevalence and characteristics of tremor in the NARCOMS multiple sclerosis registry: a cross-sectional survey". BMJ Open. 5 (1): e006714. doi:10.1136/bmjopen-2014-006714. PMC 4289717. PMID 25573524.
- ↑ Frohman EM, Zhang H, Kramer PD, Fleckenstein J, Hawker K, Racke MK, Frohman TC (September 2001). "MRI characteristics of the MLF in MS patients with chronic internuclear ophthalmoparesis". Neurology. 57 (5): 762–8. PMID 11552000.
- ↑ Mills DA, Frohman TC, Davis SL, Salter AR, McClure S, Beatty I, Shah A, Galetta S, Eggenberger E, Zee DS, Frohman EM (August 2008). "Break in binocular fusion during head turning in MS patients with INO". Neurology. 71 (6): 458–60. doi:10.1212/01.wnl.0000324423.08538.dd. PMID 18678831.
- ↑ Kim JS (May 2004). "Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction". Neurology. 62 (9): 1491–6. PMID 15136670.
- ↑ Beck RW, Trobe JD (1995). "What we have learned from the Optic Neuritis Treatment Trial". Ophthalmology. 102 (10): 1504–8. PMID 9097798.
- ↑ "The 5-year risk of MS after optic neuritis: experience of the optic neuritis treatment trial. 1997". Neurology. 57 (12 Suppl 5): S36–45. 2001. PMID 11902594.
- ↑ Gutrecht JA, Zamani AA, Slagado ED (1993). "Anatomic-radiologic basis of Lhermitte's sign in multiple sclerosis". Arch. Neurol. 50 (8): 849–51. PMID 8352672.
- ↑ Al-Araji AH, Oger J (2005). "Reappraisal of Lhermitte's sign in multiple sclerosis". Mult. Scler. 11 (4): 398–402. PMID 16042221.
- ↑ Sandyk R, Dann LC (1995). "Resolution of Lhermitte's sign in multiple sclerosis by treatment with weak electromagnetic fields". Int. J. Neurosci. 81 (3–4): 215–24. PMID 7628912.
- ↑ Kanchandani R, Howe JG (1982). "Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature". J. Neurol. Neurosurg. Psychiatr. 45 (4): 308–12. PMID 7077340.
- ↑ Boissy AR, Cohen JA (September 2007). "Multiple sclerosis symptom management". Expert Rev Neurother. 7 (9): 1213–22. doi:10.1586/14737175.7.9.1213. PMID 17868019.