Rheumatic fever physical examination
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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
Physical examination of patients with rheumatic fever is usually remarkable for fever, cardiac murmurs, and erythema marginatum.[1][2]
Physical Examination
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)
HEENT
Cardiac examination
Cardiac involvement is the second most common complication of rheumatic fever. Signs include:[3][4][5][6]
- Tachycardia
- Jugular venous distension, S3 or occasionally a summation gallop may be noted if the patient demonstrates 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) (usually accompanied by aortic insufficiency and early diastolic murmur)
- Aortic stenosis (systolic ejection murmur)
- Mitral stenosis (mid diastolic murmur)
- Pericardial friction rub and low intensity heart sounds may be evident if pericardium is involved causing pericarditis and pericardial effusion
Respiratory examination
- Dull on percussion in presence of pleural effusion
- Decreased breath sounds may be noted in presence of an accompanying pleural effusion
- Basilar crackles may be heard on auscultation, suggestive of pulmonary edema
Neurological examination
- Sydenham's chorea (St. Vitus' dance, occurring very late in the disease for at least three months from onset of infection; see video #1)[7]
- Hand writing samples
- Spooning sign (flexion of the wrists and extension of the fingers when the hands are extended)
- Pronator sign (turning outwards of the arms and palms when held above the head)
- Inability to maintain protrusion of the tongue
- Milk maids sign (intermittent increase and decrease of hand grip pressure; see video #2)
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Abdominal examination
- Ascites (if heart failure and fluid overload are present)
Extremities
- Arthritis, often large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints) are involved progressing below-upwards.[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.
- Subcutaneous nodules in approximately 10% of rheumatic fever patients, usually appearing on extensor surface of limbs, and over bony prominences such as elbows, knees, ankles and knuckles, and are generally painless.[1]
- Pedal edema possible if congestive heart failure and fluid overload are present.
Skin
- Erythema marginatum is a pink-red rash frequently located on trunk, limbs, and seldom on face.[2]
- It appears as non-pruretic macules or papules extending centrifugally outwards with central clearing and raised outer margins.
- Ruddiness of the skin secondary to rheumatic vasculitis may also be observed.
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.